Early warning systems and the organisational dynamics of standardisation

This thesis adopts a combined sociological and health services research approach to examining the implementation of standardised risk assessment tools, ‘early warning systems’, in medical wards. The data collection involved, over a three-year period from 2006 to 2008, ethnographic observations and 37 semi-structured interviews with staff in four UK hospitals that participated in the Health Foundation’s Safer Patients Initiative. Critical illness in hospitalised patients can be a predictable event preceded by observable physiological abnormalities, but research suggests that general wards may experience difficulty in detecting and responding to patient deterioration. As a result, growing numbers of acute hospitals are implementing early warning systems designed to detect and respond to early signs of patient deterioration. These systems involve track-and-trigger and rapid response mechanisms which seek to achieve accountability for standard risk management practices among doctors and nurses. The study found that accountability in relation to bedside observations was constituted through a combination of hierarchical accountability for fulfilling formal responsibilities, and horizontal accountability which encouraged sensible use of formal rules and responsiveness to calls for help and assistance. Although staff views on early warning systems were very positive, the findings also suggested that these systems may lead to undesirable practice and fail to manage certain aspects of risk. Problems identified with early warning systems included false reassurance, unnecessary alerts and ritualistic compliance, which could create unnecessary work and cause discomfort to patients. Among staff, reciprocal senses of obligation and responsibility helped to manage such problems, but could be obstructed by poor team work. The thesis suggests that focus on the alert system overshadowed accountability for the day-to-day management of early warning systems within teams. Managing the mundane may help both organisations and their staff to prevent and prepare for emergency situations, and reduce the fear of being implicated in poor management of risk.