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In this opinion, we offer a new perspective on the important and persistent problem of diagnostic errors for patients with non-specific complaints (NSCs). As an increasing number of complex patients present clinicians with challenging diagnostic work in the time-pressured and high-volume contexts of EDs, we need to improve how clinicians and healthcare organizations can understand and perform safe diagnostics for patients with NSCs. The combination of a growing number of patients with NSCs and the ways in which clinicians use the categories 'non-specific complaints' and 'non-specific diagnosis' in diagnostic work in emergency departments presents a growing patient safety concern especially for older patients with multimorbidity that require the integration of clinical and organizational research. We argue why the growing numbers of patients with NSCs and clinicians' use of these categories have implications for patient safety both within and beyond the acute care context. We end by pointing to the importance of an interdisciplinary patient safety research agenda, ideally followed by the development of targeted usable protocols for older multimorbid patients with non-specific complaints. [ABSTRACT FROM AUTHOR]

This paper describes the historical emergence of an accountable quality in public policies and reforms of the UK National Health Service: that is a notion of quality which is expressed through accounting and other formal measurement and management devices. It also specifies the idealized subject of an accountable quality, homo qualitus, and attends to instances of his/her incomplete realization. Doing so contributes to the problematization and rethinking of the way that accounting, professionalism, and the relationship between the two, are often understood. It shows that an accountable quality involves attempts to transform accounting from something external to, and imposed upon, or selectively adopted by, medical professionals into a measure of, in principle, any healthcare workers' individual enthusiasm for, and commitment toward, quality itself. The incomplete nature of this transformation offers insights into complex ways in which discourse and practice may interact. [ABSTRACT FROM AUTHOR]

Over the past decades, insights from behavioral sciences have gained traction as sources for designing public policy and for governing areas of collective concerns. It has become increasingly common to ascribe 'flawed' decision-making to systematic heuristics and cognitive biases of citizens and experts. This popular behavioral approach to public organizing is anchored in a very particular model of human behavior, namely what we label homo fallibilis or the model human fallibility. This model grew out of a critique of neoclassical economics' homo economicus but ended as a new recipe for predicting and regulating human behavior. To conceptualize the model of human fallibility and to understand its ability to travel intellectually and empirically, we trace it historically to Simon's bounded rationality, over Tversky and Kahneman's systematic biases and to recent nudge literature. Next, we illustrate how and by what means the model travels into different areas of public service provision in strikingly similar ways. We finally suggest that the model of human fallibility risks giving way to an "anti-human stance" that promotes a particular type of behavioral design in ever more areas of public governance at the expense of alternative ways of governing that enhance discretion, expertise, training, and habituation. [ABSTRACT FROM AUTHOR]

Policy reforms of public service encounters often seek to control, delegate, or eliminate discretion at the frontline. In this article, we show that rather than eclipsing discretion, the technologies meant to standardize and optimize decision making in public service delivery introduce rough categorizations and scripts for action that make new types of discretionary responses and workarounds necessary. Here, accounts of street-level discretion as grounded in self-serving coping strategies are inadequate to capture discretion-as-used in the frontline encounter. The article proposes a Weberian ethics of office approach to frontline discretion that contributes to current more appreciative perspectives on street-level discretion. Through a comparative ethnography of first encounters in three Danish public service bureaucracies, we develop a typology of office-based discretionary responses to standardization. We label the three types as adaptive handling , attentive compensation , and affective encouragement. Our study of doctors, midwives, and citizen-service bureaucrats suggests that discretionary possibilities differ in relation to organizational context and level of professional training. However, across cases the discretionary responses are indicative of the frontline practitioners' casuistic practices of balancing professional virtues, client-orientation, and managerial demands in the quest to deliver fair and responsive services. Accordingly, securing the conditions for the exercise of discretion in frontline encounters is essential to the responsible provision of public services. [ABSTRACT FROM AUTHOR]

Despite the centrality of bureaucracy to both the theory and the realities of street-level bureaucracy, street-level scholars have rarely engaged with the concept of bureaucracy as such. We argue that Weber's perspective on bureaucracy represents an indispensable source that may help us align the theoretical foundation of street-level scholarship with its empirical findings and bring attention to aspects of street-level work that are often overlooked. Drawing on a value-based reading of Weber, we propose an ethics of office-approach that allows us to see frontline workers' discretionary practices as an integrated aspect of their bureaucratic ethos, which enables them to handle complex demands and multiple obligations. The ethics of office-approach further recognizes that their actual possibilities for doing so are related to their training and expertise within specific life orders characterized by different purposes and ethical codes. The approach therefore calls for contextual sensitivity. To develop our argument, and demonstrate the analytical range and usefulness of the ethics of office-approach, we present three case examples based on ethnographic studies of midwifery care, child protection, and citizen services. [ABSTRACT FROM AUTHOR]

In recent years, questions of 'character' have become increasingly prominent in a range of policy contexts, from education to social welfare and from business to healthcare. What unites these various contemporary paens is an assumption that building 'character' is a crucial component of ethics and that it holds the key to establishing and maintaining virtuous conduct; moreover, that the cultivation of 'character' is at best under-valued and at worst actively undermined and denigrated in any number of contemporary economic and organizational practices. In this paper, we seek to interrogate key aspects of this upsurge of interest in 'character' as it has been articulated in particular recent and on-going debates about the reform of organizational life. We argue that this 'turn' suffers precisely from an abstraction and lack of contextual specificity - not simply in relation to questions of 'character formation,' but also in regard to matters of organization, and indeed the relationship of the one to the other - that severely curtails both its ethical reach and explanatory power. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to explore how the patient comes to be seen as a solution to governance problems.Design/methodology/approach The paper studies health policy discourse in Denmark from 1970 to 2000. Based on an analysis of national policy documents, the paper traces how the patient is redefined as part of governance problems.Findings The paper suggests that “the new patient” coincides with changes in healthcare governance and is not just a clinical concern. The persona of the patient has been mobilized in dissimilar ways in addressing specific policy problems, resulting in both a duty-based idea of a socio-economically responsible patient and a rights-based idea of a demanding health-service consumer.Research limitations/implications The study is limited to policy documents that address healthcare governance in one country. It does not describe the broader evolution of patient ideas or the practical impact of political discourses.Practical implications Practitioners should expect to encounter conflicting views of patient responsibilities, interests and involvement. Such conflicts are not only related to a lack of conceptual clarity but are indicative of how the new, active and responsible patient has become a key clinical concern and a central element of health policy governance.Originality/value The paper contributes to the understanding of “the new patient” in discussions on patient-centred healthcare and empowerment by emphasizing the definition of the patient in a political context. The latter has often been ignored in existing research. [ABSTRACT FROM AUTHOR]

This article explores an apparent paradox of stability and change in patient safety thinking and practice. The dominant approach to patient safety has largely been focused on closing 'safety gaps' through standardisation in seemingly stable healthcare systems. However, the presupposition of system stability and predictability is presently being challenged by critics who insist that healthcare systems are complex and changing entities, thereby shifting focus towards the healthcare organisation's resilient and adaptive capacities. Based on a close reading of predominant patient safety literature, the article analyses how a separation between stability and change is articulated in ontological, historical, and situated terms, and it suggests the way in which predetermining healthcare settings as either stable or unstable paves the way for a system engineering approach to patient safety that pre-empts certain types of safety solutions. Drawing on John Dewey's influential ideas about the interconnectedness of stability and change, this prescriptive perspective is discussed and challenged. It is suggested that only by rethinking the relationship between change and stability can patient safety efforts begin to address the uncertainty of medical practice as well as the necessary competences of healthcare professionals to act with 'safety dispositions' as a precondition for delivering safe care. [ABSTRACT FROM AUTHOR]