Understanding context for quality improvement: artefacts, affordances and socio-material infrastructure.

Against a backdrop of growing concern for patient safety and service quality, modern health-care systems are witnessing a proliferation of improvement initiatives. The impact is often variable, however, and a key theme to emerge from evaluations of these efforts is a recognition of the effects of local context on the success or otherwise of an intervention. However, the 'context' tends to be understood in terms of higher order issues such as structure, culture and leadership. This article explores a dimension of context not typically taken into account in the health-care improvement literature: the infrastructural context. Many quality improvement interventions hinge on the introduction of artefacts to support behavioural change in the workplace. Despite calls from scholars of technology in practice for a greater acknowledgement of the role of such mundane artefacts in supporting the organisation of health-care work, they are rarely considered in these terms in evaluations of improvement efforts. In this article, I argue that understanding the potential generative effects of artefacts for quality improvement purposes requires an understanding of their 'affordances' and how these relate to the socio-material infrastructure into which they are to be introduced, and/or the technologies they are designed to replace. Integrated care pathway implementation is examined to illustrate this position. Drawing on qualitative case studies of integrated care pathway development processes undertaken in the UK National Health Service and ethnographic research on the international care pathway community, I consider the infrastructural reasons behind the challenges of making pathways work in organising health care, and why, contrary to the aspirations of their proponents, they often appear to increase rather than decrease paperwork.