Katherine Kellogg

The integration of artificial intelligence (AI) technologies into mental health holds the promise of increasing patient access, engagement, and quality of care, and of improving clinician quality of work life. However, to date, studies of AI technologies in mental health have focused primarily on challenges that policymakers, clinical leaders, and data and computer scientists face, rather than on challenges that frontline mental health clinicians are likely to face as they attempt to integrate AI-based technologies into their everyday clinical practice. In this Perspective, we describe a framework for “pragmatic AI-augmentation” that addresses these issues by describing three categories of emerging AI-based mental health technologies which frontline clinicians can leverage in their clinical practice—automation, engagement, and clinical decision support technologies. We elaborate the potential benefits offered by these technologies, the likely day-to-day challenges they may raise for...

This 1.5-year ethnographic study of a U.S. medical center shows that avoiding loss of autonomy and work intensification for less powerful actors during digital technology introduction and integration presents a multisited collective action challenge. I found that technology-related participation problems, threshold problems, and free rider problems may arise during digital technology introduction and integration that enable loss of autonomy and work intensification for less powerful actors. However, the emergence of new triangles of power allows for novel coalitions between less powerful actors and newly powerful third-party actors that can help mitigate this problem. I extend the political science perspective of experimentalist governance to examine how a digital technology-focused, iterative collective action process of local experimentation followed by central revision can facilitate mutually beneficial role reconfiguration during digital technology introduction and integration. ...

An important barrier to organizational change is that, even when social movements influence the state to change policies, these new policies are often implemented in ways that do not facilitate the achievement of movement goals. In this twenty- month field study of organizational change in education systems in five states within the United States, we observed social movement actors in all of the states influence policy in line with movement goals. However, two states accomplished greater organizational change among schools involved in the education initiative than did the other four states. We demonstrate that administrative activists– state administrators who work in partnership with social movement actors and use administrative practices to specify and direct action within ambiguous implementation regimes– are critical to the change process. These findings have implications for social movement theorists’ understanding of organizational change.

This two-year ethnographic study of the primary care departments in two U.S. hospitals examines how managers can bring about micro-level institutional change in professional practice even when such change challenges professionals’ specialized expertise, autonomy, individual responsibility, and engagement in complex work, which previous research has shown to create difficulties. In this study, managers in both hospitals attempted to implement the same patient-centered medical home (PCMH) reforms among doctors, had the same external pressures for micro-level institutional change, worked under the same organizational and reimbursement structure, and had the same contextual facilitators of micro-level institutional change present within their organizations. But managers in one hospital successfully accomplished change in professional practice while those in the other did not. I demonstrate that managers can accomplish micro-level institutional change in professional organizations using ...

The weakened relationship between organizational research and management practice has created missed opportunities for management practitioners and organizational scholars alike to enrich their work through closer collaboration. Well-designed intervention research has the potential to address the implementation gap between what we know about the changes that are desired in organizations and what we know about how to make those changes a reality. This panel symposium seeks to assess the current state of intervention research in organization studies through a lively discussion between five top scholars who have used different intervention research approaches in their work. The panelists represent intervention research approaches including collaborative interactive action research, process consultation, time series design, natural experiment observational design, and randomized control field experiments; each panelist has used these approaches to understand the process of change at the individual, group and ...

In this comparative ethnographic case study of the implementation of a reform related to the Affordable Care Act in two community health centers, I find that professionals may not compete to claim new tasks (and thereby not implement reform) if these tasks require them to acquire information unrelated to their professional expertise, use work practices that conflict with their professional identity, or do impure or low-value tasks that threaten their professional interests. In such cases, reform may be implemented if lower-status workers fill in the gaps in the division of labor between the professions targeted by the reform, playing a brokerage role by protecting each profession’s information, meanings, and tasks in everyday work. When the new tasks represent professionally ill-defined problems, brokers can be more effective if they use buffering practices rather than connecting practices—managing information rather than transferring it, matching meanings rather than translating th...

This 12-month ethnographic study of an early entrant into the U.S. car-sharing industry demonstrates that when an organization shifts its focus from developing radical new technology to incrementally improving this technology, the shift may spark an internal power struggle between the dominant engineering group and a challenger occupational group such as the marketing group. Analyzing 42 projects in two time periods that required collaboration between engineering and marketing during such a shift, we show how cross-occupational collaboration under these conditions can be facilitated by a radical flank threat, through which the bargaining power of moderates is strengthened by the presence of a more-radical group. In the face of a strong threat by radical members of a challenger occupational group, moderate members of the dominant engineering group may change their perceptions of their power to resist challengers’ demands and begin to distinguish between the goals of radical versus mo...

In our study of an interactive marketing organization, we examine how members of different communities perform boundary-spanning coordination work in conditions of high speed, uncertainty, and rapid change. We find that members engage in a number of cross-boundary coordination ...

There is a growing awareness of the critical role that professions play in advanced economies. Professionals and professional service firms are key advisors, analysts, defenders and developers of the major institutions that underpin capitalist economies. As ...

One of the great paradoxes of inequality in organizations is that even when organizations introduce new programs designed to help employees in traditionally disadvantaged groups succeed, employees who use these programs often suffer negative career consequences. This study helps to fill a significant gap in the literature by investigating how local employer practices can enable employees to successfully use the programs designed to benefit them. Using a research approach that controls for regulatory environment and program design, we analyze unique longitudinal personnel data from a large law firm to demonstrate that assignment to powerful supervisors upon organization entry improves career outcomes for individuals who later use a reduced-hours program. Additionally, we find that initial assignment to powerful supervisors is more important to positive career outcomes—that is, employee retention and performance-based pay—than are factors such as supervisor assignment at the time of p...

We explore how members of a community of practice learn new tools and techniques when environmental shifts undermine existing expertise. In our 20-month comparative field study of medical assistants and patient-service representatives learning to use new digital technology in five primary care sites, we find that the traditional master-apprentice training model worked well when established practices were being conferred to trainees. When environmental change required introducing new tools and techniques with which the experienced members had no expertise, third-party managers selected newer members as trainers because managers judged them to be agile learners who were less committed to traditional hierarchies and more willing to deviate from traditional norms. This challenged community members’ existing status, which was based on the historical distinctions of long tenure and expertise in traditional tasks. In three sites, the introduction of this illegitimate learning hierarchy spa...

The widespread implementation of algorithmic technologies in organizations prompts questions about how algorithms may reshape organizational control. We use Edwards' (1979) perspective of "contested terrain," wherein managers implement production technologies to maximize the value of labor and workers resist, to synthesize the in-terdisciplinary research on algorithms at work. We find that algorithmic control in the workplace operates through six main mechanisms, which we call the "6 Rs"-employers can use algorithms to direct workers by restricting and recommending, evaluate workers by recording and rating, and discipline workers by replacing and rewarding. We also discuss several key insights regarding algorithmic control. First, labor process theory helps to highlight potential problems with the largely positive view of algorithms at work. Second, the technical capabilities of algorithmic systems facilitate a form of rational control that is distinct from the technical and bureaucratic control used by employers for the past century. Third, employers' use of algorithms is sparking the development of new algorithmic occupations. Finally, workers are individually and collectively resisting algorithmic control through a set of emerging tactics we call algoactivism. These insights sketch the contested terrain of algorithmic control and map critical areas for future research.

This two-year ethnographic study of the primary care departments in two U.S. hospitals examines how managers can bring about micro-level institutional change in professional practice even when such change challenges professionals' specialized expertise, autonomy, individual responsibility, and engagement in complex work, which previous research has shown to create difficulties. In this study, managers in both hospitals attempted to implement the same patient-centered medical home (PCMH) reforms among doctors, had the same external pressures for micro-level institutional change, worked under the same organizational and reimbursement structure, and had the same contextual facilitators of micro-level institutional change present within their organizations. But managers in one hospital successfully accomplished change in professional practice while those in the other did not. I demonstrate that managers can accomplish micro-level institutional change in professional organizations using ''subordinate activation tactics''-first empowering and motivating subordinate semi-professionals to activate their favorable structural position vis-à-vis the targeted professionals on behalf of managers and next giving semi-professionals positional tools to use in their daily work to minimize the targeted professionals' concerns about the threats associated with change.

The widespread implementation of algorithmic technologies in organizations prompts questions about how algorithms may reshape organizational control. We use Edwards' (1979) perspective of "contested terrain," wherein managers implement production technologies to maximize the value of labor and workers resist, to synthesize the in-terdisciplinary research on algorithms at work. We find that algorithmic control in the workplace operates through six main mechanisms, which we call the "6 Rs"-employers can use algorithms to direct workers by restricting and recommending, evaluate workers by recording and rating, and discipline workers by replacing and rewarding. We also discuss several key insights regarding algorithmic control. First, labor process theory helps to highlight potential problems with the largely positive view of algorithms at work. Second, the technical capabilities of algorithmic systems facilitate a form of rational control that is distinct from the technical and bureaucratic control used by employers for the past century. Third, employers' use of algorithms is sparking the development of new algorithmic occupations. Finally, workers are individually and collectively resisting algorithmic control through a set of emerging tactics we call algoactivism. These insights sketch the contested terrain of algorithmic control and map critical areas for future research.

This 12-month ethnographic study of an early entrant into the U.S. car-sharing industry demonstrates that when an organization shifts its focus from developing radical new technology to incrementally improving this technology, the shift may spark an internal power struggle between the dominant engineering group and a challenger occupational group such as the marketing group. Analyzing 42 projects in two time periods that required collaboration between engineering and marketing during such a shift, we show how cross-occupational collaboration under these conditions can be facilitated by a radical flank threat, through which the bargaining power of moderates is strengthened by the presence of a more-radical group. In the face of a strong threat by radical members of a challenger occupational group, moderate members of the dominant engineering group may change their perceptions of their power to resist challengers' demands and begin to distinguish between the goals of radical versus more-moderate challengers. To maintain as much power as possible and prevent the more-dramatic change in engineering occupational goals demanded by radical challengers, moderate engineers may build a coalition with moderate challengers and collaborate for incremental technology development.

Much of the change that social movements try to accomplish requires changing practices inside organizations, yet reform implementation is difficult to achieve. This comparative case study of two hospitals demonstrates that implementing reform inside organizations may require internal reformers not only to mobilize with one another but also to stand up to internal defenders' countertactics in everyday encounters. Because reformer alliances across identity lines often require reformers with different statuses to collaborate with one another, defenders can divide reformer coalitions by linking reform practices to a status characteristic associated with lower-status reformers, denigrating higher-status reformers by associating them with these practices, and reintegrating higher-status reformers into the defender group. When status threat inside an organization is high to begin with, higher-status reformers are likely to be concerned about loss of privilege in the face of defenders' status-based countertactics and, in response, distance themselves from reform practices and align themselves with defenders to protect their identity and its rewards. This can undermine the multi-identity reformer coalition and cause change to fail. These findings regarding status-based countertactics contribute to our understanding of social movement implementation and microinstitutional change.

In this comparative ethnographic case study of the implementation of a reform related to the Affordable Care Act in two community health centers, I find that professionals may not compete to claim new tasks (and thereby not implement reform) if these tasks require them to acquire information unrelated to their professional expertise, use work practices that conflict with their professional identity, or do impure or low-value tasks that threaten their professional interests. In such cases, reform may be implemented if lower-status workers fill in the gaps in
the division of labor between the professions targeted by the reform, playing a brokerage role by protecting each profession’s information, meanings, and tasks in everyday work. When the new tasks represent professionally ill-defined problems, brokers can be more effective if they
use buffering practices rather than connecting practices—managing information rather than transferring it, matching meanings rather than translating them, and maintaining interests rather than transforming them—to accomplish reform. By playing a buffering role in the
interstices between existing professional jurisdictions, lower-status workers can carve out their own jurisdiction, becoming a brokerage profession between existing professions that need to collaborate with one another for reform to occur.

Recent policy reforms encourage quality improvement (QI) innovations in primary care, but practitioners lack clear guidance regarding spread inside organizations. We designed this study to identify how large organizations can facilitate intraorganizational spread of QI innovations. We conducted ethnographic observation and interviews in a large, multispecialty, community-based medical group that implemented three QI innovations across 10 primary care sites using a new method for intraorganizational process development and spread. We compared quantitative outcomes achieved through the group's traditional versus new method, created a process model describing the steps in the new method, and identified barriers and facilitators at each step. The medical group achieved substantial improvement using its new method of intraorganizational process development and spread of QI innovations: standard work for rooming and depression screening, vaccine error rates and order compliance, and Pap smear error rates. Our model details nine critical steps for successful intraorganizational process development (set priorities, assess the current state, develop the new process, and measure and refine) and spread (develop support, disseminate information, facilitate peer-to-peer training, reinforce, and learn and adapt). Our results highlight the importance of utilizing preexisting organizational structures such as established communication channels, standardized roles, common workflows, formal authority, and performance measurement and feedback systems when developing and spreading QI processes inside an organization. In particular, we detail how formal process advocate positions in each site for each role can facilitate the spread of new processes. Successful intraorganizational spread is possible and sustainable. Developing and spreading new QI processes across sites inside an organization requires creating a shared understanding of the necessary process steps, considering the barriers that may arise at each step, and leveraging preexisting organizational structures to facilitate intraorganizational process development and spread.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially.

There has been much concern regarding the impact of work-hour reforms on the operative case volume of surgical residents. Operative case volume by PGY year and clinical rotation were examined to determine if changes in work hours affected residents' operative case volume. A careful but aggressive plan of work-hour reduction was devised for the residency of the authors' institution with the goal to decrease work hours while maintaining optimal patient care and resident education, including operative case volume. Changes made included hiring physician extenders (PEs), decreasing call schedules to every fourth night (with the next day free from clinical activities-Q4) or call from home (HC), and night float rotation coverage for services (NF). Case volume before (academic year 2002) and after (academic year 2003) changes were compared by PGY year, for all residents and for specific rotations-private general surgery, which had changes of PE, HC, and NF for PGY5; PE, Q4 and NF for PGY1 and 10% exemption for work hours; Churchill service (a resident-run ward teaching service), which had changes of PE and Q4 for PGY5 and PGY1 and 10% exemption for work hours; and vascular surgery, which had HC and NF for PGY5. Total case volume on these services was likewise compared. Statistical analysis was by student t test. Operative case volume was measured with data from the resident-entered information on the ACGME Surgical Operative Log (SOL). Case volume for PGY4 residents could not be compared over this time period because of lack of access to archived data by PGY year for graduated residents through the ACGME SOL. Work hours before and after rotation changes were measured with an intranet-based monitoring system. This article is a retrospective review of the affects of these work-hour changes on operative case volume. Total case volume for the general surgical services (both private and Churchill) was unchanged over this period (5905 in 02, 5930 in 03), and likewise for the vascular service (1101 vs 1196). Overall, there was no change in mean operative volume per year for surgical residents in this program (231 cases in 2002, 246 cases in 2003; p = 0.61). For PGY5 residents, the case volume increased; 339 cases 02, 390 in 03, and p = 0.05. Mean case volume for PGY5 residents increased on the private general surgery service (136 in 02, 160 in 03, p = 0.03), but it remained stable on the Churchill service (137 in 02, 158 in 03, p = 0.39) and vascular service (65 in 02, 73 in 03, p = 0.42). For PGY3 residents, case volume remained stable (171 in 02, 187 in 03, p = 0.62), as it did for PGY2 and PGY1 residents (PGY2: 148 in 02, 121 in 03, p = 0.12; PGY1: 265 in 02, 246 in 03, p = 0.23). However, operative case volume for PGY1 residents did decrease on the private general surgery service (mean 52 cases per month 02, 43 cases per month 03, p = 0.07), while remaining stable on the Churchill service (mean 23 cases per month 02, 25 cases per month 03, p = 0.66). Average hours worked per week decreased significantly over the time period. Before work-hour reforms, residents' average work hours were as follows: PGY1 105, PGY2 97, PGY3 78.7, PGY4 111, and PGY5 92. After the changes, average work hours were PGY1 81.5, PGY2 77.7, PGY3 78.7, PGY4 75.5, and PGY5 75.9. Work-hour limitation can be devised to maximize resident education, optimize patient care, and maintain resident operative volume. Although some changes (HC, PE, NF) seemed to increase the operative case volume for PGY5 residents, others had no effect (Q4, HC). There does not seem to be a clear relationship between types of changes and case volume. At the PGY1 level, Q4 and PE changes decreased operative experience on 1 rotation but not on another, although the difference in this decrease seems clinically insignificant. Individualization of changes to meet the needs of specific rotations seems more important than specific changes in coverage pattern. Perhaps the most important finding is that changes can be made to bring work hours into compliance without materially effecting operative case volume.

... Using findings from a 15 month ethnography of this surgical teaching hospital, I demonstrate that institutional stability and change occur only insofar as they are negotiated in interactions between particular workplace members with particular reasons for wanting either to ...

To assess the impact of the 80-hour resident workweek restrictions on surgical residents and attending surgeons. The ACGME mandated resident duty hour restrictions have required a major workforce restructuring. The impact of these changes needs to be critically evaluated for both the resident and attending surgeons, specifically with regards to the impact on motivation, job satisfaction, the quality of surgeon training, the quality of the surgeon's life, and the quality of patient care. Four prospective studies were performed at a single academic surgical program with data collected both before the necessary workforce restructuring and 1 year after, including: 1) time cards to assess changes in components of daily activity; 2) Web-based surveys using validated instruments to assess burnout and motivation to work; 3) structured, taped, one-on-one interviews with an external PhD investigator; and 4) statistical analyses of objective, quantitative data. After the work-hour changes, surgical residents have decreased "burnout" scores, with significantly less "emotional exhaustion" (Maslach Burnout Inventory: 29.1 "high" vs. 23.1 "medium," P = 0.02). Residents have better quality of life both in and out of the hospital. They felt they got more sleep, have a lighter workload, and have increased motivation to work (Herzberg Motivation Dimensions). We found no measurable, statistically significant difference in the quality of patient care (NSQIP data). Resident training and education objectively were not statistically diminished (ACGME case logs, ABSITE scores). Attending surgeons perceived that their quality of their life inside and outside of the hospital was "somewhat worse" because of the work-hour changes, as they had anticipated. Many concerns were identified with regards to the professional development of future surgeons, including a change toward a shift-worker mentality that is not patient-focused, less continuity of care with a loss of critical information with each handoff, and a decrease in the patient/doctor relationship. Although the mandated restriction of resident duty hours has had no measurable impact on the quality of patient care and has led to improvements for the current quality of life of residents, there are many concerns with regards to the training of professional, responsible surgeons for the future.

... Page 5. Katherine Kellogg is associate professor of organization studies at the MIT Sloan School of Management. The University of Chicago Press, Chicago 60637 The University of Chicago Press, Ltd., London © 2011 by The University of Chicago All rights reserved. ...

One of the great paradoxes of institutional change is that even when
top managers in organizations provide support for change in response
to new regulation, the employees whom new programs are
designed to benefit often do not use them. This 15-month ethnographic
study of two hospitals responding to new regulation demonstrates
that using these programs may require subordinate employees
to challenge middle managers with opposing interests. The
article argues that relational spaces—areas of isolation, interaction,
and inclusion that allow middle-manager reformers and subordinate
employees to develop a cross-position collective for change—are
critical to the change process. These findings have implications for
research on institutional change and social movements.

In our study of an interactive marketing organization, we examine how members of different communities perform boundary-spanning coordination work in conditions of high speed, uncertainty, and rapid change. We find that members engage in a number of cross-boundary coordination practices that make their work visible and legible to each other, and that enable ongoing revision and alignment. Drawing on the notion of a " trading zone, " we suggest that by engaging in these practices, members enact a coordination structure that affords cross-boundary coordination while facilitating adaptability , speed, and learning. We also find that these coordination practices do not eliminate jurisdictional conflicts, and often generate problematic consequences such as the privileging of speed over quality, suppression of difference, loss of comprehension, misinterpretation and ambiguity, rework, and temporal pressure. After discussing our empirical findings, we explore their implications for organizations attempting to operate in the uncertain and rapidly changing contexts of postbureaucratic work.

One of the great paradoxes of organizational culture is that even when less powerful members in organizations have access to cultural tools (such as frames, identities, and tactics) that support change, they often do not use these tools to challenge traditional practices that disadvantage them. In this study, I compare data about work practice change from my own field study of an elite teaching hospital (conducted in the early 2000s) to previously reported data from field studies of two similar hospitals (one conducted in the 1970s and one in the 1990s). I demonstrate that although cultural toolkits supporting change may allow less powerful organization members to see traditional practices as running counter to their interests, they may not be able to significantly change traditional practices unless they also have access to what I call political toolkits (including tools such as staffing systems, accountability systems, and evaluation systems) that support change. Although cultural tools allow them to reinterpret practices that disadvantage them as unfair, political tools allow them to feel optimistic that others will help them effect change. Whereas cultural tools enable them to develop a " we " feeling with other reformers, political tools allow them to coordinate their change efforts. And although cultural tools provide them with a repertoire of contentious tactics, political tools afford them a sense of security that they can battle defenders of the status quo without ruining their careers. These findings contribute to our understanding of both the cultural construction of organizational life and social movement processes.