The poetics of quality : an anthropological exploration of quality improvement in Scottish healthcare

Abstract

This thesis is an ethnographic exploration of how “quality” is made into an object of improvement in healthcare. Focusing on a specific method and brand of quality improvement (that of the Boston-based Institute of Healthcare Improvement [IHI]) and a particular quality improvement initiative (that undertaken by the Scottish Patient Safety Programme [SPSP] to improve the safety and quality of healthcare in NHSScotland), I frame “quality improvement” as an endeavour that can be approached as a practice of entification: described by Larsen as the process by which something is summoned into existence from an inchoate state, and made into a bounded entity. I seek to “thicken” the problematic of entification as laid out by Larsen through an analysis guided by linguistic anthropology and semiotics; governmentality and critical accounting studies; and the literatures on numbers and standards. The research is based on participant observation at IHI and SPSP training events conducted over an eighteen-month period across Scotland; interviews with people involved in the Scottish quality improvement initiative; and textual analysis of training and promotional materials associated with IHI and the SPSP. The dissertation unfolds in an iterative manner, constantly revisiting a series of binaristic contrasts that I use strategically in order to highlight what I discern to be two historically distinct styles of entification. I also develop the notion of “ideologies of entification” in order to better grasp how contrasting styles of entification are related to different social imaginaries and structures of feeling, and to engage the ways they are bound up with processes of subject-formation. I strive to link these insights to a range of other theoretical interventions, and in so doing provide a meaningful theoretical synthesis; an expansion of the concept of entification; and critical insights meant to enhance on-going efforts to improve the safety and quality of healthcare.