The Turn Toward Value: An ethnography of efficiency and satisfaction in the American hospital
This dissertation is an ethnographic examination of the policies and practices intended to create “health care value” in American hospitals – a phrase encompassing the goals of greater efficiency in hospital work, a reduction in perceived waste of time and effort, and increased patient satisfaction. To explore these phenomena, and the ways in which these abstract notions are brought into practice as hospitals seek to meet quality reporting metrics, I trace the ways in which the turn toward value shapes the contemporary notion of good medical care. Specifically, I explore how quality improvement approaches such as “Lean thinking” and “continual process improvement” are used in hospitals to improve efficiency and satisfaction and shape patient and provider experiences of care. Lean, originally developed as the Toyota Production System, is increasingly popular in healthcare and focuses on increasing “value” through eliminating “waste,” especially time spent waiting.
The concept of patient flow has become a central organizing principle for the movement of patients through the hospital. This dissertation explores how this imperative of patient flow is central to the logic of efficiency – the assumption that improving efficiency will result in better patient care – and shapes all aspects of care delivery. The production of efficiency and satisfaction metrics as quality indicators are central to how clinicians, administrators and Lean consultants understand the health of the hospital. As clinicians are enlisted as agents of continual process improvement in addition to providing clinical care, I show how care practices are displaced from patients onto to the system. Through the proliferation of and reliance on patient satisfaction surveys as market-driven quality indicators, I argue that today, satisfaction has become a proxy for care and reduces patients’ experiences of care to quantified metrics. Ultimately, this dissertation argues that the turn toward value shifts the locus of care from the patient to administrative processes, and in doing to places the system itself – rather than the patient -- as the object of care.
This investigation is based on two years of research conducted between 2013-2015 in community hospitals and among Lean consultants in California and nationally.