Childbirth Re-written as an Organizational Event: The Impact of Accountability Artifacts on Coordination of Routines in a Labor & Delivery Unit

This dissertation explores the tensions between accounting for patterns of action and coordinating actual work routines in a healthcare organization. How do accountability artifacts that prescribe action, such as protocols that are materially embedded in health information technologies, interact with and impact situated and emergent coordination of medical work? This dissertation theorizes the relationship between accountability artifacts and coordination of routines through an in-depth ethnographic investigation of nursing work in a hospital obstetrical unit. An underlying goal of this dissertation is to engage with the broader question of how current auditing technologies are impacting healthcare provision.;This dissertation shows how routines prescribed in an Electronic Medical Record (EMR) are incongruous with the actual work performed by nurses. It focuses, in particular, on the performance of seemingly simple tasks such as fulfilling medication orders as well as the intense work that occurs during acute moments of childbirth. Artifacts that prescribe routines do not result in certain patterns of action; instead, nurses are both engaging in emergent and situated coordinating to accomplish patient care as well as creating a good account of this care that adheres to prevailing norms for how care should be delivered. The effect is exacerbated by the digital capabilities of the EMR. Working through the EMR is like inhabiting a living audit that must be both appeased and worked around at the same time. Coordinating multiple routines is a skillful physical phenomenon. The choreography of coordinating involves elements of movement, rhythm, and constant adjustment based on the situation at hand. This dissertation argues that it is through embodied choreography that nurses resolve the disjunctures between patient care and accounting routines. It reveals that an examination of routines is key to a socio-material understanding of medical work, as artifacts frame routines and actions taken in one routine to correct frame "overflows" leak into other routines in the ecology; for example, the introduction of a synthetic hormone to correct a "disordered" contraction pattern actually creates disorder in other, related routines. end with a final sentence? Taken together, this research suggests that accountability artifacts tend to interfere with the ability of medical personnel to engage in successful coordinating of work, and highlights the need for a philosophical shift in auditing practices and design of accountability artifacts.