The complexity of simple things: An ethnographic study of the challenge of preventing hospital-acquired infections

Hospital-acquired infections (HAIs) are one of the most common complications of medical care in the United States (U.S.). They exact a tremendous toll in morbidity, mortality, and costs. Despite increased attention, knowledge of why they occur, the availability of evidence-based, inexpensive practices to prevent their spread, and policies meant to incentive hospitals to reduce them, HAIs remain common. Many U.S. hospitals do not adopt basic practices to prevent HAIs and the ones that do adopt these practices have considerable difficulty in getting frontline clinical staff to reliably comply with them. This dissertation investigates why implementation and compliance in HAI prevention is so challenging. The findings are based on 22 months of ethnographic observation at one hospital that undertook an organization-wide initiative to prevent HAIs. I combine observational data with 103 in-depth interviews with a sample of hospital staff that varied by occupational group, location in the organizational hierarchy, and work area. In three empirical chapters, the study illustrates how the social context in which HAI prevention efforts occur shapes the enactment of simple and high-impact infection prevention practices. First, I find that while frontline clinical staff recognize that preventing HAI is important, they describe this goal as occasionally coming into conflict with other equally important goals involved in providing patient care. Second, I find that the formal criteria of what counts as an HAI is frequently ambiguous and poorly aligned with what frontline clinical staff believe to be truly hospital acquired. Tightly coupling accountability sanctions, like nonpayment for HAIs or public reporting of HAI rates, may, via reactivity mechanisms, have the unintended consequence of making infection prevention more difficult by threatening its credibility as an organizational goal. Third, I find that despite significant resources devoted to improving the hospital\u27s safety culture in order to change healthcare worker behavior to reduce HAIs, this formal improvement program was limited in its ability to transform organizational practice. I argue that this is because it did not address politically uncomfortable, yet crucial, social dynamics such as politics, and inequalities in power and authority that contributed to infection risks