[Relevance of the theory of High Reliability Organizations in Assisted Reproductive Technology]. / Intérêt de la théorie des organisations à haute fiabilité en Assistance Médicale à la Procréation (AMP).

OBJECTIVES: The objective of this study was to assess the value of applying operating principles for High Reliability Organizations (HROs) to Assisted Reproductive Technology (ART) centres in order to optimise their operation and results. METHODS: Two exploratory qualitative case studies, in the form of ethnographic observations, were conducted in two public hospitals (Antoine-Béclère Hospital, Clamart and Nantes University Hospital). The studies analysed the structural and functional characteristics of these centres compared to HROs. Specific interviews, based on the HRO model from Roberts and Rousseau (1989), were also carried out. RESULTS: The in vitro fertilisation (IVF) procedure is comprised of a sequence of steps for which success depends on the cooperation of a range of medical staff across various specialties. Patients themselves must also play an active part in the protocol. From the different points analysed, the comparison between the characteristics of IVF activity at the ART units and those of HROs reveals structural and functional similarities, however there are also cultural differences. CONCLUSION: The study concluded that ART centres are complex healthcare organisations that face similar challenges to HROs and that they could improve their operational performance by adopting an HRO culture. To confirm the interest of this strategy, it would be useful to clarify these preliminary results by extending the exploratory study to include several public and private ART centres, and to explore the patient/couple dimension before initiating an interventional study.

Discursive practice - lean thinking, nurses' responsibilities and the cost to care.

PURPOSE: The purpose of this paper is to explore the literature regarding work intensification that is being experienced by nurses, to examine the effects this is having on their capacity to complete care. The authors contend that nurses' inability to provide all the care patients require, has negative implications on their professional responsibility. DESIGN/METHODOLOGY/APPROACH: The authors used institutional ethnography to review the discourse in the literature. This approach supports inquiry through the review of text in order to uncover activities that remain institutionally accepted but unquestioned and hidden. FINDINGS: What the authors found was that the quality and risk management forms an important part of lean thinking, with the organisational culture influencing outcomes; however, the professional cost to nurses has not been fully explored. RESEARCH LIMITATIONS/IMPLICATIONS: The text uncovered inconsistency between what organisations accepted as successful cost savings, and what nurses were experiencing in their attempts to achieve the care in the face of reduced time and human resources. Nurses' attempts at completing care were done at the risk of their own professional accountability. PRACTICAL IMPLICATIONS: Nurses are working in lean and stressful environments and are struggling to complete care within reduced resource allocations. This leads to care rationing, which negatively impacts on nurses' professional practice, and quality of care provision. ORIGINALITY/VALUE: This approach is a departure from the standard qualitative review because the focus is on the textual relationships between what is being advocated by organisations directing cost reduction and what is actioned by the nurses working at the coalface. The discordant standpoints between these two juxtapositions are identified.