School of Accounting Seminar Series Semester 2, 2012

Imagining accounting governance as indexical through Michel Serres’

“Theory of Relations”

Gillian Vesty RMIT University

Date: Friday, 31st August 2012 Time: 3.00pm – 4.30pm Venue: Tyree Energy Technologies Building LGO5

(Refer to campus map reference H6 here)

Australian School of Business School of Accounting

Imagining Accounting Governance as Indexical through

Michel Serres’ “Theory of Relations”      

Gillian  Vesty  School of Accounting

RMIT University Melbourne, Australia

 

 

 

Abstract  

Engaging  Michel  Serres  ‘theory  of  relations’  this  paper  provides  the  means  to  theoretically  explore   the   connections   between   high-­‐level   accounting   conceptualisations   and   the  multiplicity  of  expertise  and  low-­‐level  practices.  A  typology  has  been  developed  from  stories  of  clinical  governance  and  practices  directed  at  linking  ‘good  care’  with  rational  marketplace  concerns  of  efficiency  and  efficacy.   In   this  study,  a  relational   form  of  accounting  emerges,  offering  a  practical,  and  political,  means  for  accounting  intervention.    

Introduction  

A   decade   ago,   Brown   (2002)   lamented   that   the   work   of   Michel   Serres,   an   influential  precursor  to  actor-­‐network  theory  (ANT)  and  prolific  poststructuralist  author,  had  failed  to  find  an  audience  in  the  British  and  North  American  social  science  literature.    Greater  access  to  Serres  work  has  been  made  possible  through  English  translations.  However,  his  work  and  influence   on   ANT   is   still   not   widely   known,   even   within   the   growing   body   of   accounting  literature  applying  ANT1.    Serres  use  of  rich  metaphors  challenges  us  to  rethink  traditional  boundaries  between  individual  and  collective  as  well  as  science,  politics,  society  and  nature.    He   invites  us   to   see   the   connections  between   seemingly  disparate  worlds   through   simple  stories  that  build  to  powerful  models,  which  he  then  rigorously  tests  and  extends.        In   this  paper,  Serres  “theory  of   relations”  provides  an  empirical  basis  on  which   to  explore  the   dynamics   of   accounting   in   healthcare   settings,   one   that   is   complicated   by  heterogeneous  expertise  and  requisite  knowledge  translation  between  the  accounting  and  clinical  domains  (Miller,  Kurunmäki  &  O’Leary,  2008;  Oborn,  Barrett  &  Rancko,  2010).    The  governance  of  public  healthcare  provision  is  rigorously  contested  along  the  lines  that  there  

                                                                                                               1  Acknowledgements  of  Serres  influence  is  found  in  seminal  works  such  as  Latour  (Pasteurization  of  France),  Deleuze  and  Guttari    (A  Thousand  Plateaus)  as  well  as  in  work  by  ANT  founders  (Callon,  1980;  Latour,  1983;  Law,  1999).  Callon’s    (1986)  Sociology  of  Translation  was  inspired  by  Serres  Hermes  series.  See  Brown  (2002)  for  further  discussion  on  the  influences  of  Serres  philosophy.    My  aim  with  this  paper  is  to  introduce  Serres  to  the  accounting  academy,  demonstrating  how  works  such  as  Serres’  “The  Parasite”  (1982);  “The  Natural  Contract”  (1995);  “The  Five  Senses:  A  Philosophy  of  Mingled  Bodies”  (2009);  and,  Serres  and  Latour’s  Conversations  on  Science,  Culture,  and  Time  (1995)  can  continue  to  contribute  to  our  theoretical  developments.      2  Serres  (1982)  would  define  this  as  the  creation  of  “quasi-­‐objects”  as  a  passage  from  thing  (commerce)  to  object  (money,  goods)  and  thence  to  quasi-­‐object  (accounting  information),  which  is  a  marker  of  a  relation.  3  Pierce’s  notion  of  semiotic  is  adopted  in  this  paper  to  explain  parasitic  exchange  as  three  different  modes  of  

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is   best   practice   ‘out   there’   and   ‘ideal’   governance   structures   that   can   be   achieved  (Braithwaite   &   Tavaglia,   2008).   While   much   of   the   mainstream   accounting   governance  literature   is   aligned  with   this   view,  Roberts   (2009)  points  out   that   there   is  nothing  wrong  with  the  efforts  to  achieve  transparent  governance,  as  long  as  it   is  recognised  that  perfect  transparency  is  not  possible.    In  adopting  this  view,  this  paper  seeks  to  define  new  ways  to  explore   the   interdisciplinary  efforts   to  achieve  accounting  governance.    Empirical   research  from  a  public  hospital  setting  is  used  to  develop  the  analytic  typology.    It   has   been   argued   that   governance   from   a   conformance   (to   legislative   accounting  standards)  perspective  only  creates  a  “hyper-­‐surveillance  and  control  machine”  (Ezzamel  &  Reed,  2008:  598).    Similarly,  in  public  health  care  provision  clinicians  argue  that  accounting  efficiency   must   necessarily   be   balanced   with   performance   from   a   clinician’s   practice  viewpoint   (Braithwaite   &   Travaglia,   2008).     A   conformance-­‐only   approach   to   governance  undermines   the   important   connections   to   the   internal   control   structure  and   the  practices  and   processes   associated   with   social   arrangements   that   necessarily   flow   beyond  organisational   bounds   (Power,   2009;   Chapman,   Cooper   &   Miller,   2009).   There   is   an  acknowledgement   that   broader   business   responsibilities,   risk   management   and   strategic  control  procedures  must  be  better  represented  in  governance  system  designs  (IFAC,  2004;  OECD,   2004;   ICGN,   2008;   see   also  Miller   &   O’Leary,   2000;   Bhimani   &   Soonawalla,   2005;  Stevens,   2010).     Yet   there   is   minimal   research   focusing   on   the   processes   that  make   this  happen  (Ahrens  &  Chapman,  2007).        This   research   thereby   addresses   Ahrens   and   Chapman   (2007)   call   for   a   focus   on   situated  practices.     It   aims   to   bring   to   life,   through   Serres,   the   contingent   connecting   activities  between  organisational  experts.    In  seeking  to  extend  the  view  that  accounting  knowledge  translation  is  a  hybridising  globality  (Kurrunmäki,  2004;  Miller,  Kurunmäki  &  O’Leary,  2008;  Power,  2009;  Chapman,  Cooper  &  Miller,  2009)  this  paper  does  not  focus  on  governance  as  transparent   disclosure   of   conformance   to   accounting   ideals,   or   consider   hybridisation   of  expertise  from  an  accounting-­‐  or  clinical-­‐only  perspective.    Instead,  a  typology  is  developed  to  help  focus  on  the  connecting  activities  between  the  legislated  public  health  care  funding  model   and   the   situated   clinical   accounting   practices.  Using   Serres,   I   contend   that  we   can  make  a  difference  with  research  techniques  that  examine  the  “correspondence  work”  or  the  conflation   activities   of   multiple   experts   that   sanction   a   form   of   reality   as   constitutional  procedure  (Latour,  2004:  248).    The   aims   of   this   paper   is   to   contribute   to   the   emerging   accounting   literature   that   views  accounting   as   a   trail   of   connections   and   separations  with   practices   that  make   it   a   viable  technique  (Briers  and  Chua,  2001;  Ahrens  &  Chapman,  2007;  Mouritsen  Hansen  &  Hansen,  2009;  Power,  2009;  Quattrone,  2009)2.  ANT  theorists  suggest  mainstream  approaches  tend  to  fold,  simplify  and  summarise  complexity;  while  performative  approaches  are  perpetually  unfolding   and   seeking   out   new   complexities   (Quattrone,   2009;   Boedker,   2010).     These  researchers   follow   economic   technologies   as   they   come   into   being,   are   rearranged,  transformed  or  become  momentary  conventions  (Preston,  Cooper  &  Coombes,  1992;  Chua,  1996;   Mouritsen,   1999;   MacKenzie,   Muniesa   &   Siu,   2007;   Mouritsen,   Hansen   &   Hansen,  

                                                                                                               2  Serres  (1982)  would  define  this  as  the  creation  of  “quasi-­‐objects”  as  a  passage  from  thing  (commerce)  to  object  (money,  goods)  and  thence  to  quasi-­‐object  (accounting  information),  which  is  a  marker  of  a  relation.  

 

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2009;  Quattrone,  2009).    In  this  growing  body  of  literature,  research  gaps  continue  to  draw  attention.    If  we  situate  our  studies  entirely  in  the  accounting  domain,  minimal  attention  is  paid  to  theorising  the  accounting  correspondence  work  or  framing  of  relations  that  emerge  between  momentary  connections  of  otherwise  heterogeneous  parties.    Brown,  points  out  that:   “In  an  age  where   the   rhetoric  of   interdisciplinarity   is   commonplace,   it   still   shocks   to  encounter   work   [such   as   Serres]   where   the   deliberate   crossing   (and   re-­‐crossing)   of  disciplinary  boundaries   is   seriously  put   into  practice”   (2002:1).     The  broader   challenge   for  accounting   researchers   is   to   make   sense   of   the   social   setting,   ignore   the   disciplinary  boundaries  and  embrace  the  multiplicity  of  behaviours,  contexts  and  expert  accounts.      This   research   thereby   takes  up   the  challenge   to  develop   research   techniques   that  help   to  look   beyond   the   efficacy   of   theorised   conceptual   frameworks   or   the   capacity   of   the  individual   accounting   parts,   standards   and   measurement   models   that   represent  accounting’s   foundational   ideals.     Where   a   financial   accountant   may   view   ‘earnings  management’  as  an  upset  to  accounting  order  (and  recognise  a  disconnect  between  practice  and  the  conceptual  accounting  framework)  the  management  accountant’s  story  might  be  a  valuation   problem,   finding  with   fault   in   the   performance  measurement  model’s   ability   to  adequately  represent  organisational  strategy.    In  a  public  hospital,  a  clinician  may  decide  to  treat   a   patient   for   reasons   that   appear   to   be   at   odds  with   the   accountant’s   system   that  directs   government   funded   care.     Researchers,   trapped   in   domain   specific   framings  frequently   ignore   the  everyday   connections  between  actors  as   they  work   consciously  and  unconsciously   to   reconcile   individual   difference   and   achieve   enterprise-­‐wide   governance  goals.     Accounting   research,   while   focused   on   calculation,   fails   to   recognise   the  representational   properties   of   numbers   and   accounts   and   they   ways   they   articulate,   not  only  systems  of  value,  but  map  pathways  to  achieving  social  order.    This  paper  attempts  to  move   the   research   focus   beyond   the   traditional   domain   specific   and   relativist   framing  devices.   A   relational   typology   is   developed   to   enable   researchers   to   deliver   relevant  research   on   gaps   that   currently   exist   between   theoretically   derived   accounting  conceptualisations  and  the  growing  multiplicity  recognised  in  practice  (Parker,  2012).      In   the   following   sections   I   begin   by   discussing   Serres   theory   of   relations   in   terms   of  theorising   the   ‘space’   between   high   level   governance   procedures   and   the   connecting  activities   that  occur  between  heterogeneous  organisational   experts.    Drawing  on  Serres,   I  recognise   the   ‘space’   as   an   interference   (a   parasite)   that   must   be   attended   to   but   is  frequently  ignored  in  the  academic  literature.     I  follow  with  the  clinical  governance  setting  and   present   four   stories   that   offer   the   connections   between   the   otherwise   disparate  accounting   and   clinical   practices.     These   stories   become  my   analytic   typology   defined   as  three   representational   forms.     I   discuss   each   of   the   representational   forms   in   turn   and  explain  my  adapted  model  of  relations  through  grounding  in  the  clinical  governance  setting.    I   conclude   this  paper  with  discussion  on  how  this   typology  of  accounting  practices  can  be  applied   in   other   emerging   governance   structures,   in   particular,   those   that   challenge   the  links  between  commerce,  society  and  nature.      Theorising  the  ‘space’:  accounting  representation    

Accounting  depictions  of  corporate  activities  typically  contain  vocabularies  of  efficiency  and  effectiveness  and  management  structures  focused  on  strategy  achievement  and  healthy  risk  

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management  ideals.    Accounting  is  commonly  seen  as  a  system  of  communication;  a  means  to  picture  a  governable  entity,  a  stable  linguistic  model  of  observable  objects,  underpinned  by   a   fixed   ontology   (see   arguments   posed   by   Thompson   (1991)   and   Bloomfield   &  Verdubakis,   (1997)).     In   this   form  of   picturing   accounting   governance   is   achieved   through  formalised   procedures   and   protocols   to   sanction   corporate   activities   in   a   way   that   links  accounting   representation  with   the   ideals   of   “moral   order”   (Woolgar,   1991).     Accounting  can   thus   be   understood   as   a   high   order   connecting   device,   or   representational   form   that  engenders   governance:     “The   basic   function   of   representation   can   be   summarized   as  presenting   (making   present)   one   thing   in   terms   of   another,   a   representation   is  what   can  “stand  in  for”  an  absence  and  thus  make  it  present  …”  (Bloomfield  &  Vurdabakis,  1997:  644-­‐645).       In   examining   the   detailed   processes   of   making   accounting   present,   two   aspects  become   apparent:   the   moral   order   itself,   and   the   associated   representational   activities  performed   by   the   lower   levels   to   achieve   this   order.   In   the   accounting   literature,   this  representational  activity  is  regarded  as  situated  practice  (Ahrens  &  Chapman,  2007)  .        

In   drawing   on   sociology   literature   engaging   with   semiotics,   I   consider   three   different  representational   modes   of   accounting:   iconic,   symbolic   and   indexical   representations.3  In  the   first,   iconic   representation   is   recognised   in   the   macro-­‐economic   models   that   help  express   a   constitutionally   accepted,   societal   order   (Woolgar,   1991).     Examples   of   iconic  accounting  models  might  include  the  Conceptual  Framework  (even  in  its  re-­‐development  to  meet   international   standards),   well-­‐respected   models   such   as   the   Capital   Asset   Pricing  Model   (CAPM)   or   possibly   even   emerging   environmental   models,   such   as   The   FullCam  Carbon  Accounting  Model.     Each  has   emerged   from   rigorous   research   and   recognised   for  the  solid  theoretical  foundations  that  interpret  and  manage,  through  accounting,  the  state  of  society  or  nature.    Following  the  introduction  of  New  Public  Management  (Hood,  1991),  the  internationally  adopted  public  hospital-­‐funding  model,  Casemix,   is  also  included  in  this  broad   repertoire  of   iconic  accounting   representations.    Based  on  Diagnosis-­‐Related  Group  (DRG)  methodology   this  macroeconomic  model   of   governance   has   likewise   attempted   to  engender  social  order,  this  time  through  public  healthcare  provision.      The   second   form   of   generalising   is   recognised   by   its   symbolic   valuing   properties.     Chua  (1995)  described  how  the  Casemix  funding  model  was  first  theorised  in  its  entirety,  and  then  separated  into  activity-­‐based  cost  categories  of  patient  care.    Calculable  values  derived  for  each   of   the   diagnoses,   provide   acceptable   standard   costs   that   can   then   be  managed   and  audited.     The   individual   component   values   are   given   voice  by   key  practitioners   and  other  stakeholders   (accountants,   clinicians,   health   economists,   system   engineers,   government  administrators,  patients,  families  and  community)  who  all  play  a  role  in  the  cost  and  delivery  of  patient  care.    If  there  is  any  disagreement,  the  derived  standard  or  individual  DRG,  can  be  taken   out   of   the   model,   modified   and   re-­‐valued.     All   the   while   the   overarching   health  economic   theory   is   undisputed,   the   iconic   status   of   the   high-­‐order   conceptual   model  remains   intact,  even  when  component  parts  are  re-­‐worked.    The  funding  models  arguably  create  order  by  generalising  standard  values  for  the  average  clinical  inliers  that  meet  clinical  domain  specific  practices  (Llewellyn  and  Nothcott,  2001).  Nevertheless,  if  outliers  generate  

                                                                                                               3  Pierce’s  notion  of  semiotic  is  adopted  in  this  paper  to  explain  parasitic  exchange  as  three  different  modes  of  representation:  iconic,  symbolic  and  indexical.    See  Hoopes’  (1991)  interpretation  of  C.S  Pierce’s  seminal  work  on  the  typology  of  signs  in  literature  and  Verran  who  uses  Pierce’s  typology  of  signs  to  explain  economic  models  as  the  signatory  of  numbers  (2011,  p.7).    

 

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too   much   [theoretical]   noise   and   the   model   no   longer   meets   collective   needs,   its   iconic  status   is   brought   into   question   (Kuhn,   1962).     In   a   recent   example,   MacKenzie’s   (2010)  demonstrated  the  failure  of  the  Black-­‐Scholes  model  during  the  global  financial  crisis.      The  ability  for  the  situated  practices  to  come  together  and  represent  the  whole  is  a  function  of  the  capacity  to  which  accounting’s  framing  device  engages  stakeholders  (Briers  &  Chua,  2001).   All   stakeholders   are   engaged   in   ongoing   valuing   processes   so   they   are   not   only  represented  in  the  model  but  are  given  value  in  healthcare  audits.    The  value  of  healthcare  provision   can   be   expressed   numerically   (for   example,   as   a   %   GDP)   and   provides   globally  comparitive  means   to   demonstrate   the   value   of   each   of   the   stakeholders   in   the   funding  model.     Both   valuing   and   ordering   are   routine   activities   performed   by   accountants   and  others.  Sometimes   they   think  of   the  accounting  models  as  symbols   representing  value   for  the   processes   of   healthcare   audit   or   alternatively   as   systematic   processes   effecting   a   fair  way   to   allocate   scarce   government   resources   among   its   public   hospitals.     Yet,   as   we  generalise  back  and  forth  between  order  and  value  -­‐  the  activities  of  the  multiple  situated  experts  disappear   in  the  processes  of  commensuration,  their  practices  become  part  of  the  background,   taken   for  granted   in   the  model   (Latour,  1983).      This  everyday  commonplace  conflation  of  value  and  order  is  recognised  as  the  third  indexical  form  of  representation  but,  to  date,  remains  largely  unrecognised  by  the  research  academy  (Verran,  2011).        Accounting  research  is  largely  centred  on  iconic  modelling  and  finding  imperfections  in  the  ‘theory’  argued  for.    Alternatively,  there  are  the  relativists  who  are  concerned  with  missing  values  (or  denied  variables)  that  must  be  included  in  a  re-­‐worked  model.    What  accounting  research   does   not   do   well   is   acknowledge   the   power   of   indexical   generalisation   that  proceeds  simultaneously  as  both  value  and  order.    Indexical  moments  are  recognised  in  the  simultaneous   relations   of   ordering   and   re-­‐ordering   responses   to   values   that   become  calculable.  With   attention   on   indexical   generalisation,   sociologists   like   Verran   suggest  we  can   improve  our  understanding  of  accounting  by  following  the  connecting  activities  of  the  actors.  As  Serres  explains,  if  we  only  focus  on  the  accounting  governance  message,  we  only  see   betrayal   (or   conformance)   to   the   expected   moral   order,   or   governance   reality.    However,  if  we  recognise  the  accounting  space  as  a  third  representational  form  researchers  are  offered  new  opportunities.        In  the  following  section  I  propose  Serres’  theory  of  relations  as  a  typology  to  test  indexical  generalisation   in  the  public  healthcare  domain.    This  provides  an   interesting  setting,  given  the   now   well-­‐established   iconic   and   symbolic   representational   practices   and   frequently  juxtaposed  clinical  and  accounting  views.    I  introduce  the  indexical  space  as  Serres’  parasite,  or  interference  –  “one  living  off  another  when  the  other  does  not  even  suspect  it”    (Serres  &  Latour,   1995:134).     When   theorising   accounting’s   connecting   activities,   Serres’   work  suggests  we  must  study  the  performative  space  as  if  it  were  a  marker  of  a  relation,  a  quasi  object  (Serres,  1982).    In  this  way  we  can  see  the  potential  for  change  and  innovation.    

Theorising  the  ‘space’:  Serres’  theory  of  relations  

Recognised  by   its  Deleuzean  rhizomatic-­‐style  connectivity  and  “inhabiting  the  heart  or  the  middle  of  the  world”  the  parasite  finds  his  host  and  feverishly  seeks  out  the  truth  (Deleuze  &   Guttari,   1987;   Deleuze,   1988).     The   ultimate   position   “sojourning   at   the   summit,   the  

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height,   the   best   of   truth”   is   a   locus   of   control   saved   for   the   Parasite   (Serres   and   Latour,  1995:   134).     Serres’   (1982)   explains   pictorially   how   his   theory   of   relations   is  made   up   of  three  parts,  production,  exchange  and  position  (see  Figure  1  below).      

 

 

 

“The  three  positions  are  equivalent.    Each  is  in  a  line  with  the  others,  and  each  can  play  the  third”  (Serres,  1982:  19)  

 

 

Figure  1:  Serres’  Theory  of  Relations      The   first,   ‘production’   initiates   a   system  of   giving   and   receiving   (‘exchange’)   that   at   some  stage  goes  through  a  black  box  (parasited).    Serres  explains:    “In  the  beginning  is  production:  the   oil   crusher,   the   butter   churn….   Real   production   is   undoubtedly   rare,   for   it   attracts  parasites  that  immediately  make  it  something  common  and  banal”  (1982:  4).  In  this  paper,  Serres  production   is  used  as  a  means   to  describe   the  expert  activities  of  human  and  non-­‐human  actors  involved  in  generating  collective  governance  accounts.        Exchange   is   the  process  of  giving  up  production.  Exchange  can  be  of  a  voluntarily  nature,  such  as  the  given-­‐and-­‐take  of  comparable  tangible  or  intangible  production.    Exchange  can  also   be   involuntary   or   unknown.     Importantly,   exchange   permits   parasitic   entrance.     The  Parasite   feeds   on   the   bi-­‐products   of   exchange,   and   in   turn   effects   collective   production,  permanently  altering  its  state.    Serres  (1982)  metaphor  is  the  country  rat,  invited  by  the  city  rat  to  feast  on  the  crumbs  at  the  table  of  the  farmer  who  has  invited  a  guest  to  dinner.    He  explains  the  exchange  as  a  guest/host  relationship  where  good  food  is  exchanged  for  good  company.  “The  guest  is  the  stranger,  the  interrupter,  the  one  who  receives  the  soup,  agrees  to   the  meal.    The  guest   receives,  accepts,   is   invited,  and   is  a  passerby”   (Serres,  1982:  15).  The  guest   is   the  one  who  accepts   the  production,  but   in   turn  offers   conversation  and  wit  (another  form  of  production).    The  host  is  the  one  who  gives,  offers,  invites  and  is  master.    The  parasite   engages  with   this   activity.   But  who   is   guest   and  passerby,   host   and  master?    What   is   position   and   the   objects   of   exchange?   According   to   Serres   -­‐   ‘guest’,   ‘host’   and  ‘parasite’  are  all  the  same  interchangeable  word:      

“He   is   the  object  as  well,   for   in   the  exchange  of   the  word  we  cannot  see  where   the  exchange  of  the  thing  is.    An  invariable  term  through  the  transfer  of  the  gift.    It  might  be  dangerous   not   to   decide   who   is   the   host   and   who   is   the   guest,   who   gives   and   who  received,  who  is  the  parasite  and  who  is  the  table  d’hôte,  who  has  the  gift  and  who  has  the  loss,  and  where  hostility  begins  within  hospitality”  (1982:  15-­‐16).      

 The  parasite  engages  with  society  while  at  the  same  time  is  guest/host,  created,  re-­‐created  and   mobilised   by   network   accomplishments.     Translating   this   metaphor   into   a   hospital  setting,   I   imagine   the   systems   of   governance   aimed   at   engaging   with   society,   while   the  clinicians   and   accountants   are  mobilised   by   their   network   to   provide   auditable   values   of  

Position    

Production   Exchange    

Source:  Adapted  from  Serres,  1982:  19  

 

 

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 Gillian  Vesty  

     

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clinical  care.  Emerging  from  Serres  parasitic  logic  the  ‘theory  of  relations’  is  the  negotiation  of  a  collective  from  heterogeneous  parts.  Through  this  negotiation,  position  is  achieved.    In  my   reading   of   Serres,   I   recognise   parasitism   as   not   necessarily   threatening,   rather   a  metaphor   for   the   creation   of   a   system   –   a   common   world   where   position   is   informed  meaning  making.  The   first   step   in   the   construction  of  a   common  world   is   the  production.  Production  follows  with  an  attachment  to  a  collective  (for  example,  in  the  all-­‐encompassing  systems   that   enable   the   corporate   regulatory   and   strategic   business,   or   clinical  environments   to   communicate).   Accounting   captures   production   and   converts   it   to   a  common   language   enabling   exchange.     The   conformance   or   performance   activities   are  negotiated  as  a  single  language  and  the  parasite  is  the  offer  to  negotiate  towards  a  ‘better’  governance   world.   There   is   a   to   and   fro   negotiation   between   the   parts.     Accounting  facilitates  and  channels  but  at  the  same  time  hybridises  existing  processes  and  activities  and  becomes  hybridised  in  the  process  (see  Lépinay,  2007;  Lépinay  &  Callon,  2009).        Exchange  is  the  space  where  the  complex  parts/whole  relations  work  to  momentarily  bind  the   conformance   and   performance   technologies   as   collective   enterprise   governance.  Accounting  for  clinical  governance  might  be  examined  as  participating   in  order  or   likewise  engaged   in   representing  order   in   a   specific  way—as   value.  Networks   “sometimes  work   in  ordering  and  at  other   times   in   valuing—it  depends.  And  because   it  depends  and  because  often  those  who  love  numbers  are  unaware  of  what  they  depend  on,  we  find  dissembling  in  numbering:   ends   disporting   themselves   as  means;   ordering   in   the   guise   of  mere   valuing”  (Verran,  2011:  3).    While  high-­‐level  accounting  conceptualisations  are   recognised   for   their  desired   iconic   accounting   governance   status   and   accounting   practices   recognised   as   the  symbolic  generalisations  of   individual  experts  working  their  clinical  governance  practices  –an  important  indexical  space  is  revealed  where  the  reiterative  exchange  can  be  examined  to  make   sense  of   the   complexities   associated  with   representation.     This   reiterative   indexical  process  of  generalisation  acknowledges  the  constitutive  categories  in  the  production  of  new  forms  of  collective  governance.      Importantly  this  space,  the  parasite,  or  position,   is  recognisable  as  “informed”  indexicality.  In  other  words,  rather  than  not  knowing  whether  the  representational  activity  is  ordering  or  valuing,  the  position  achieved  in  the  processes  of  production  and  exchange  is  the  creation  of  a  third  representational  governance  object  (Serres,  1982:  38).  In  this  knowing  exchange,  the  space   between   high-­‐level   structures   and   low-­‐level   action   is   revealed,   thereby   allowing  political  intervention.      I   now   put   this   typology   of   representation   to   practice   in   the   clinical   governance   setting  theorising   through   stories   of   clinical   and   accounting   approaches   to   governance.   In   the  discussion  that  follows,  I  first  describe  the  contemporary  clinical  governance  setting  and  the  emergence  of  clinical  governance  frameworks.    I  present  four  carefully  selected  stories  from  this  setting  to  show  accounting  performativity  as  the  indexical  manoeuvre  operating  in  the  space  between   the   symbolic   and   iconic   forms  of   generalising.     I   conclude   this   paper  with  discussion  on  the  development  and  potential  use  of  this  typology  to  theorise  the  space  and  cohesive  moments  of  governance  in  other  accounting  settings.  

     

8   Vesty    

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The  Clinical  Setting    

New  Public  Management  paved  the  way  for  the  corporatisation  of  public  healthcare  around  the   Western   world   (Hood,   1991;   1995).     Government   oversight   was   achieved   through  decentralised   output-­‐based   performance   management   control   mechanisms,   the   most  important   being   the   patient   diagnosis-­‐related   group   (DRG)-­‐based   funding   model   called  Casemix   (Lowe,   2001;   Balnave   &   Reid,   2007;   Duckett,   1995;   2000;   Palmer,   1996)4.   The  success  of  the  New  Public  Management  project  was  entirely  dependent  on  the  engagement  of   clinicians,   and   the   ability   for   the   accounting   system   to   overcome   the   conflict   between  caring  and  financial  constraints  (Abernethy  &  Stoelwinder,  1995;  Chua,  1996;  Comerford  &  Abernethy,   1999;   DHS,   2000).   As   an   overarching   constitutional   commitment   to   clinical  governance,   Casemix   was   designed   to   bring   social   order   to   public   healthcare   provision  (Chua,  1996).        Early   accounting   experimentation   made   clinical   activities   visible   before   they   became  standardised  as  performance  measures  (Chua,  1996;  Star  &  Strauss,  1999).  The  professional  work   environment   was   reorganised   with   new   zones   for   inter-­‐disciplinary   accounting  practices   with   multidimensional   performance   measurement   to   communicate   the   desired  performance  (Grafton  and  Lillis,  2005;  Chan  &  Ho,  2000;  Aidemark,  2001;  Abernethy,  Horne,  Lillis   &  Malina,   2005;   Miller   et   al.,   2008;   Northcott   &   France   2008).   Through   accounting  changes,   both   costing   and   caring   governance   practice   were   more   visible   to   the   hospital  executive   and   communicated   as   a   legislated   hybrid   to   the   wider   public   hospital  constituencies   (Kurunmäki,   2004;   Miller   et   al.,   2008;   Northcott   &   France   2008).   Casemix  accounting   and   standardised   balanced   scorecard   performance   indicators   became   tightly  linked   to   legislated  external  disclosures  and  output-­‐based  performance   funds   (DHS,  2008;  Miller   et   al.,   2008;   Scobie,   Thompson,   McNeil,   &   Phillips,   2006;   DHA,   2010).   With   the  Casemix   function  of   ‘sorting’  patients  according  to  their  clinically  meaningful  categories  of  care,  “best  clinical  practice”  standards  were  thought  to  emerge  at  the  same  time  operating  as   a   strict  monitoring   device   for  medical   treatment   cost   variances   (DHS,   2000).   Acting   as  governance  mechanisms   Casemix   and  multidimensional   performance  measures   offered   a  contemporary   discourse   to   address   concerns   about   quality   and   safety   in   health-­‐care  provision   and   to   further   the   working   relationship   between   medicine   and   management  (Scally   &   Donaldson,   1998;   Braithwaite   &   Travaglia,   2008).   The   transition   from   central  control   and   input   funding   to   output   activity-­‐based   Casemix   was   not,   however,   without  debate   (Chua,   1996).     The   ‘system’   was   argued   to   recognise   clinician   work   through  performance   measures   (Star   &   Strauss,   1999),   patients   as   inliers   or   outliers,   with   the  ‘average’  patient  or  hospital   taking  precedence   in  accounting  costing  designs   (Llewellyn  &  Northcott,  2005).    

                                                                                                               4  Since  the  late  1980s  there  are  modified  version  of  the  United  States  –  diagnosis  related  group  (DRG)  method  of  categorisation  adopted  throughout  the  world.    Referred  to  as  Casemix,  this  form  of  funding  has  been  adopted  by  governments  in  Australia,  parts  of  Europe,  The  Middle  East  and  Asia  (see  http://www.casemix.com.au;  Balnave  &  Reid,  2007:  59–67).  It  is  an  activity-­‐based  costing  approach,  predetermined  around  each  DRG  classification  (every  surgical  and  medical  procedure  carefully  costed)  with  standard  costs  providing  a  consistent  pricing/funding  model  for  each  patient  treated.    Hospitals  are  reimbursed  for  the  pre-­‐determined/contracted  number  of  services  and  types  of  patient  treatments  provided  (as  an  example,  see  http://www.health.vic.gov.au).    Casemix  could  be  argued  as  generating  politico-­‐socio-­‐technical  lock-­‐in  (Callon  and  Muniesa,  2005)  with  hospital  administrators  relatively  comfortable  with  the  methodology  and  continue  to  make  investments  (Balnave  &  Reid,  2007;  Palmer,  1996).    

 

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 Gillian  Vesty  

     

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 Concerned   clinicians   continue   to   argue   that   an   overtly   rigid   “conformance”   focus   has  dominated  governance  designs,  to  the  detriment  of  their  clinical  practices  (Degeling  et  al.,  2004;   see   also  Degeling   et   al.,   2006:   p.   758).   Lost   in   the   accomplishment   of   Casemix   and  multidimensional   performance   tools   is   the   flexible,   evidence-­‐based   governance  arrangements,   underpinned   by   a   framework   of   ethics   and   trust   (Braithwaite   &   Travaglia,  2008).   Clinicians   are   calling   for   more   evidence-­‐based   clinical   practice   guidelines   and  integrated   care   pathways,   developed   through   decades   of   world   standard   medical  developments  in  clinical  care,  to  be  the  forefront  of  hospital  funding  mechanisms  (Gabbay  &  le  May,   2004;  Marshall,   2008).     Clinical   pathways   place   clinicians   in   the   centre   of   a   peer  supported   team  approach   to  patient  management  and  governance  and  as  a  best-­‐practice  model  provides  a  way   to  guide   improved  clinical  governance  practices   (Gabbay  &   le  May,  2004;  Degeling  et  al.,  2004;  Marshall,  2008;  Maliapen  &  Dangerfield,  2010).     In  maximising  collaborative   clinical   arrangements,   expertise   is   considered   in   terms   of   patient   care  activities;   timelines   of   care;   intermediate   and   long-­‐term   outcomes   as   well   as   any  documented  deviations  from  expected  results.    The  aim  is  to  focus  on  both  quality  and  co-­‐ordinated  patient  care.        The  pathways   identify   the   step-­‐by-­‐step  course  of  events   for   the   standard  patient   that   fits  within  a  diagnosis-­‐related  group   (DRG)  5.  Not  disconnected   from  Casemix   funding  models,  clinical   pathways   or   DRG-­‐processes   of   patient   care   aim   to   reduce   medical   errors   and  prevent  widespread  deviations   in   clinical   practice;   at   the   same   time  provide   an   efficiency  benefit,  through  the  economies  of  scale  generated  in  streamlining  resource  use  and  capacity  management  by  a  reduction  in  length  of  patient  stay  (Maliapen  &  Dangerfield,  2010:  259).  Developed  by   the  multidisciplinary,  global  network-­‐based  teams   in  charge  of  patient  care,  the  clinical  pathways  model  of  care  is  dynamic  in  that  there  is  a  continual  systematic  review  of  treatment  outcomes  for  each  clinical  condition  (Marshall,  2008).  This  system  accepts  that  there  must  be  exceptions  to  the  general  rule,  in  one  way  respecting  clinician  expertise  and  preserving   their   autonomy   in   providing   them   with   an   ability   to   individually   assess   and  categorise  every  individual  patient  case.  It  is  up  to  the  clinician  to  decide  whether  or  not  it  is  in   the  patient’s  best   interests   to   follow  the  prescribed  clinical  pathway.   Informed  clinician  expertise  is  built  into  the  system  offering  them  a  process  that  permits  them  to  manage  the  unexpected  or  exceptions  to  the  pathway  if  or  when  they  occur.      Clinical  pathways  for  the  top  DRGs  are  widely  consolidated  in  evidence-­‐based  best  practice  standards   but   not   fully   embedded   in   accounting   governance   designs. 6       However,   if  integrated   care   pathways   remain   closely   tied   with   the   DRG-­‐Casemix   management   and  clinical  goals,  and  are  central  to  the  proposed  big  picture  of  clinical  governance;  there  is  the  

                                                                                                               5  The  top  ten  clinical  pathways  include  cardiac  pathways,  maternity  pathways,  diabetic  foot  pathways,  surgical  pathways,  orthopaedic  pathways,  transient  ischaemic  attack  (TIA)/stroke  pathways.    For  example,  a  patient  arriving  to  emergency  department  with  chest  pain  and  suspected  heart  attach  is  treated  according  to  the  clinical  pathways  approach  –  requiring  certain  drugs  and  specified  medical  tests  within  timeframes  designed  for  optimal  outcomes.    For  further  information,  see  the  clinical  practice  improvement  centre  website,  accessed  August  2010  http://www.health.qld.gov.au/cpic/service_improve/current_sw_clin_path.asp.    6  Clinical  pathways  and  Casemix  connect  according  to  DRG  cost  efficiencies.    They  are  currently  being  used  in  the  US  for  bonus  performance  funds  and  more  recently  investigated  for  similar  use  in  Australia  (DHA,  2011).        

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potential   for   the   multidisciplinary   clinician   teams   and   administrators   to   balance   the  interconnections   and   power-­‐sharing   implications   between   the   clinical   activities   and   the  resource   accountability   dimensions   of   care   (Degeling   et   al.,   2004).   The   links   between  Casemix  and  the  balanced  scorecard  input  and  output  measures  (such  as  “hospital  clinician  caseload”,   “patient   satisfaction”,   “clinician   satisfaction”,   “repeat   episodes”,   “admissions”,  “DRG  weekly  frequency”,  “cash  flows”,  “fees  relative  to  Medicare”)  might  be  given  greater  visibility  when  clinical  pathways  become  central  in  clinical  governance  regimes  (DHA,  2010;  Maliapen  &  Dangerfield,  2010).    While  the  “patient”  might  not  necessarily  benefit  if  treated  as  a  “client”  with  the  rights  of  treatment  choice,  it  is  argued  that  a  “logic  of  care”  approach  with  flexible  accounting  arrangements  that,  recognise  the  clinical  expertise  alongside  others  in  the  patient  care  network,  will  optimise  patient  care  (Mol,  2008).        In   ways   not   widely   explored   in   accounting   literature,   the   health   care   setting   has   slowly  begun   to   embrace   the   need   for   clinical   governance   while   at   the   same   time   fostering   a  flexible  clinical  pathways  culture  where  clinical  practice  and  patient  care  is  enhanced.  In  the  following   section   I   use   stories   to   show   the   heterogeneity   of   accounting   for   clinical  governance.  Each  of  the  carefully  selected  stories  plays  an  important  part  in  explaining  the  way  clinical  pathways  as  connecting  devices  between  the  imagined  big  picture  accounts  of  clinical   governance   and   the   detailed   activities   associated   with   clinical   and   administrative  practices  of  governance.  The   stories,   guided  by  Serres’   theory  of   relations,  have   informed  my   typology   development.   I   contribute   this   novel   research   analytic   for   use   in   varying  contemporary  accounting  settings;  particularly  those  where  integrated  governance  designs  and  multiple   heterogeneous   expert   connections   are   fighting   to   achieve   their   own  diverse  modus  operandi.        Four  clinical  governance  stories  

The   following  stories  have  been  gathered   from  research   in   four  public  hospitals  –   two  are   regionally   based   and   the   other   two   are   large   metropolitan   teaching   hospitals.    Interviews   were   conducted   with   clinicians,   accountants   and   other   administrators   over   a  two-­‐year  period.    When  the  balanced  scorecard  reporting  format  was  introduced  to  public  hospitals,   I   was   invited   to   sit   in   on  management   reporting  meetings   as   senior   managers  considered   the   impact   of   the   top-­‐down   reporting   model   on   practices.   Observation   and  archival   data,   together   with   the   interviews,   enabled   me   to   develop   this   typology   of  practices.  

The  stories  that  follow  are  designed  to  elicit  the  three  modes  of  representation,  iconic,  symbolic   and   indexical   representation.     Serres’   theory   of   relations   is   used   to   explain   the  indexical  representation  by  revealing  the  parasite  in  the  processes  of  production,  exchange  and  position.    This  first  story  offered  is  a  nurse’s  recollection  from  the  past.    Set  back  in  time  before  New  Public  Management  this  story  is  used  to  demonstrate  real  production  that  will  later   be   parasitised   by   accounting   designs   and   rendered   as   average,   a   normal   inlier   cost.    The  aim  of  this  story  is  to  introduce  the  multiple  individuals  and  how  they  might  play  a  part  in  accounting  and  clinical   governance  model  designs.     Some  might  argue   the  value  of   the  governance  model   is  contingent  on  all  views  being  represented.    Others  would  expect  the  model  to  sanction  societal  expectations  of  the  administration  of  public  hospital  governance.  This   first   story   aims   to   familiarise   readers   with   difficulties   associated   with   representing  practices  in  public  health  care  provision  as  both  order  and  value.    

 

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 Gillian  Vesty  

     

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1.  Nursing  Production.  Caring  for  a  dying  patient  (as  explained  by  a  junior  nurse)  A   young   high   school   boy,   I   will   call   Jack,   too   shy   and   embarrassed   to   tell   anyone   about   his  

testicular  lump,  finally  sought  help  when  the  pain  was  too  much  to  bear.  By  then,  it  was  too  late.  He  became   one   of  my   oncology   patients.   I   was   a   junior   nurse,   not   really   that  much   older   than   Jack,  working   at   a   large   teaching   hospital   in  Melbourne,   in   the   oncology   ward.   Jack   was   reserved   and  always  extremely  polite,  not  at  all  demanding,  even  though  you  could  see  he  was   in  constant  pain.  He  tried  to  be  brave.  He  suffered  by  himself  and  so  did  his  parents  as   they  sat   there  with  him,  not  really  coming   to   terms  with   it  all.  He  had  a  younger  sister  –   they   tried   to  maintain  as  “normal”  as  possible   a   life   for   her   –   I   could   not   help   but   see   how   hard,   and   helpless   or   hopeless,   it   was   for  everyone.  Including  me.  I  popped  in  and  out,  checking  on  him  as  I  did  my  other  patients  in  my  eight-­‐hour  shift.    

We  were  generally  allocated  around  five  or  six  patients  to  care  for  during  the  day,  and  I  always  felt   bad   that   he   did   not   demand   my   time   as   much   as   my   other   patients.   I   would   try   to   make  conversation,   always   try   to  make   him   as   comfortable   as   he   could   be   –   offer   him   food   and   fluids,  check   his   pulse   and   blood   pressure   and   scribble   them   down   on   his   daily   record   chart,   which   was  located  at  the  end  of  his  bed.  I  tried  to  be  the  best  nurse  I  could,  spend  time  with  him  when  I  could,  but  felt  pretty  useless.  He  just  lay  there  in  his  bed,  locked  up  in  a  shell,  politely  and  quietly  resigned  to  his  destiny.  This  one  particular  morning  –  it  still  remains  vivid  in  my  mind  –  I  arrived  at  7am  for  my  eight-­‐hour  day  shift.  We  were  given  the  usual  handover  from  the  night  staff  and  the  senior  nurse  in  charge  of  the  day  shift  allocated  our  patients.  I  was  given  Jack,  who  was  in  a  single  room,  along  with  four  other  patients  who  were  in  an  adjacent  four-­‐bed  room.  I  usually  popped  my  head  in  to  say  hello  to  my  patients  before  I  began  the  round  of  helping  them  with  breakfast,  bathing  &  dressing  as  well  as   looking   after   their   intravenous   drips,   medications   or   wound   dressings,   and   anything   else,   if  required.    

I  looked  in  on  Jack.  He  did  not  look  good.  I  fluffed  his  pillows,  tried  to  sit  him  up  for  breakfast  and  felt  a  sudden  knot   in  my  stomach  as   I   realised  that  there  was  no  way   I  would  be  able  get  food,   let  alone  drink,  into  him  this  morning.  His  colour  was  terrible.  He  was  struggling  to  be  Jack.  More  pain  than  usual,  and  not  so  good  with  his  breathing.  I  went  to  the  nurse  in  charge  and  suggested  we  call  his  parents,   right  now,  even  though   I  knew  they  would  be   in  sometime  that  day.   I  wanted  them  to  hurry  and  I  also  wanted  to  warn  them.  I  called;  spoke  with  his  mum,  telling  her  that  Jack  was  not  so  good  this  morning.  They  should  come  in  as  soon  as  they  can.  Jack’s  mum  said,  they  would  drop  their  daughter  at  school  and  come  straight  in.  I  stayed  with  Jack,  saying  silently  under  my  breath  –  “hurry  mum  and  dad,  please  hurry”  –  but  Jack  faded  so  quickly.  He  died  as  quietly  as  he  lived.  As  I  walked  out  of  his  room,  his  parents  raced  into  the  ward  –  at  the  other  end  of  the  corridor,  looking  down  the  hallway  to  Jack’s  room  they  saw  me  come  out;  saw  the  look  on  my  face.  Jack’s  mum  collapsed  on  the  floor  in  the  hallway.  

 The   following   two   stories   demonstrate   the   process   of   exchange.     The   first   component   is  iconic   representation   while   the   second   explores   the   process   of   symbolic   representation.    These  two  stories  consider  the  ordering/valuing  practices  by  clinicians  and  administrators  as  they  negotiate  the  individual  components  of  the  iconic  funding  model.    2.  The  process  of  exchange:  Recognising  Casemix  as  a  constitutionally-­‐derived  icon?  Hospital  CEO  managing  ‘Casemix’  funding  in  a  small  public  hospital.      

The  CEO  of  one  small  public  hospital  I  visited  has  an  accounting  background.  He  explained  the  ins-­‐and-­‐outs  of  Casemix  funding  to  me,  on  a  white  board  in  his  office.  He  discussed  the  terminology  –  the  average  “length  of  stay”  for  every  DRG;  the  “inliers”  and  “outliers”  of  patient  classifications  –  WIES  or  “Weighted  Inlier  Equivalent  Separations”  where  “separations”  loosely  meant  patient  discharge  (i.e.,  

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that  they  left  the  hospital  to  go  home,  to  another  health-­‐care  facility,  or  because  they  had  died).  One  WIES  was  given  a  dollar  value  and  at  budget  time  “x”  WIES  were  allocated  to  individual  hospitals  as  part  of  their  Agreements  to  the  determined  patient  Casemix.7  He  explained  how  important  it  was  to  get  Casemix   right.   “If  we  do  not  deliver   service  performance  according   to   the  Casemix  agreement,  then  future  funding  is  cut.    This  happened  to  us  one  year.”  His  governance  role  was  outlined  to  me  on  his  whiteboard.  Checking  targets  presented  to  him  as  spreadsheets  against  those  in  the  large  bound  book   that   is   developed   annually   by   the   Department   is   about   making   sure   the   reported   Casemix  activity  matched  the  allocated,  capped  level  of  WIES  funding.  Patients  were  classified  as  a  diagnosis  group  and  may  be  inliers  or  outliers.  Although  outliers  might  indicate  excess  costs  for  the  hospital,  he  explained  how  occasionally  this  was  not  necessarily  so.  Sometimes  extended  care  patients  required  minimal   hospital   resources  while   they  were  waiting   for   placement   in   another   care   facility.   A   large  bound   book   outlining   the   Annual   Casemix   targets   for   Victorian   public   hospitals   was   the   tool   that  directed   his   accounting   production;   the  methods   of   classifying   types   of   patients,   their   treatments,  associated  costs  and  the  total  annual  revenue  the  hospital  would  receive.    

For  this  hospital  administrator,  governance  was  about  demonstrating  corporate  responsibility  by  following  and  reporting  on  the  Casemix  systems  of  compliance  –  by  making  sure  that:  there  is  equity  of   “access”   for   different   patient   classifications;   that   the   correct   number   of   Category   1,   2   and   3  patients  have  been  treated  according  to  the  right  timeframes;  “effectiveness”  can  be  demonstrated  (in  Casemix  and  associated   funding  parameters  such  as  costs  per  Casemix-­‐adjusted  separation  and  length   of   patient   stay);   acceptable   levels   of   effectiveness   in   terms   of   waiting   times   for   surgery;  quality   and   safety   in   the   service   provided.   Developing   these   accounts   was   about   accounting  production  –   for   the  CEO  on   the  whiteboard   it  was   factual,   rational  and  accepted  as  a   thoroughly  worked   through   macroeconomic   policy   or   extension   of   clinical   governance.   It   ordered   his   way   of  managing   clinical   conformance   to   government   policy;   in   general,   but   not   always.   Sometimes   the  outliers   created   a   nice   revenue   stream   for   the   hospital.   Sometimes   a   particular   Casemix   episode  created   a   financial   risk   for   the   hospital.   The   CEO   would   recognise   and   need   to   manage   the  differences  between  clinical  conformance  and  clinical  performance.  Sometimes  when  activity  did  not  match   funding,   serious   decisions   needed   to   be   made   about   bed   closures,   patient   waiting   lists,  clinician  rosters  and  engagements.    

In   conversation   with   clinicians   from   the   operating   theatre   it   was   later   explained   that   many  surgeons   seemed   to   be   operating   under   their   physical   capacity.     Some   were   frustrated   that   their  technical  prowess  was  not  recognised  in  the  funding  models.  Highly  skilled  surgeons  could  potentially  operate   on   a   lot   more   patients   than   budgeted   for   by   the   Casemix   funds.   However,   when   the  operating   theatre   list   was   constructed   (a   list   of   surgical   patients   to   be   treated   by   surgeons)   the  number   of   patients   must   exactly   meet   the   allocated   Casemix   fund   weights.   “We   can   only   do   ‘x’  number   of   tonsillectomies,   even   though   the   surgeon,   is   an   excellent   operator   and   could   safely   get  through  more  of  the  waiting  list  in  the  time  allocated  in  theatre.”  This  Casemix  amount  is  all  that  is  funded  for,  even  though  surgeons  try  to  add  more  to  their  lists  and  nursing  staff  were  rostered  (and  costs  fixed)  to  allocated  shifts.  Sometimes,  even  though  it  is  possible,  one  surgeon  was  not  allowed  to  

                                                                                                               7  More  specifically,  WIES  is  a  DRG  cost  weight,  part  of  the  inpatient  coding  and  classification  system,  that  provides  the  basis  for  payments  to  public  hospitals  in  Australia.  Under  the  Casemix  system,  hospitals  are  paid  based  upon  the  numbers  and  types  of  patients  they  treat,  not  upon  the  resources  they  use.  The  patient’s  WIES  value  depends  upon  the  amount  of  time  they  stay  in  hospital  compared  to  other  patients  with  similar  conditions  (inlier  equivalence)  and  the  relative  cost  of  treating  their  condition  compared  to  the  cost  of  other  illnesses  (cost  weight  or  relativity).  For  example,  0.19  WIES  is  allocated  to  a  same  day  chemotherapy  patient;  30.02  WIES  is  allocated  to  a  liver  transplant  patient  staying  40  days;  7.51  WIES  is  allocated  to  a  liver  transplant  patient  dying  after  3  days.  In  2008  metropolitan  hospitals  received  $3,279  per  WIES  while  country  hospitals  received  slightly  more  in  recognition  of  the  higher  fixed  costs  of  running  small  hospitals  (http://casemix.health.vic.gov.au).  It  was  pointed  out  that  “WIES  activity”  is  the  most  measured  activity  in  Victorian  Hospitals  and  “must  withstand  careful  scrutiny  by  public  hospital  managers  and  officials  in  funding  organisations”  (Duckett,  2000:  p.  120).  

 

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perform   two   procedures   under   the   one   anaesthetic   (i.e.,   a   colonoscopy   and   gastroscopy   together)  because  they  are  different  procedures  that  are  accounted  for  separately.    

The  flaws  were  regarded  as  challenges  that  could  be  sorted  by  the  system.  The  Casemix  targets  were  there  at  the  outset  and  they  were  accepted  (sometimes  grudgingly)  but  worked  towards.  As  for  changes,  it  was  a  matter  for  continual  tweaking  and  adjustment.  If  dissention  occurs,  the  system  can  be  disembedded  or  sectioned  into  its  respective  conformance  and  performance  parts  to  be  fine-­‐tuned  and   managed.   But   the   general   policy   remained   as   one   with   the   technological   zone   of   clinical  governance.   In   the   context   of   social   ordering   the   Casemix   system   was   viewed   as   a   high   level  accounting  model  that  held  iconic  status.  Kept  at  a  distance,  it  could  be  judged  and  labelled  by  both  accounting   administrators   and   clinicians   as   user-­‐friendly   or   at   times   difficult   and   behaviour  controlling.    In  this  context  it  provided  a  way  of  ordering  public  hospital  practices.  

 

3.   The   process   of   exchange:   representing   categories   that   matter   –   symbolically.     Balanced  Scorecard  implementation  -­‐  disappearing  measures  

Sitting   in   the   back   offices   of   a   large   public   hospital,   the   Senior   Management   Accountant  explained   to  me  how   they  wanted   to  do  more  with   “balanced   scorecards”  at   lower  organisational  levels.  While  the  hospital’s  performance  itself  was  measured  in  dollars  (the  ability  to  balance  funding  mechanisms  like  Casemix  with  costs)  other  non-­‐financial  performance  measures  (based  on  hospital-­‐running   and   patient   access   to   care   issues)   were   also   implicated   in   funding   mechanisms.   He   was  concerned   that   many   of   these   indicators   in   their   former   generic   balanced   scorecard   model  (categorised   as   “patient”;   “resource   use”;   “patient   care   processes”;   and,   “people,   learning   &  innovation”)   did   not   necessarily   match   with   the   actual   activities   and   processes   going   on   in   the  hospital.  He  explained  how  the  balanced  scorecard  tool  was  removed  from  the  website  when  it  was  pointed  out   that  only   the   legislated  7  Casemix-­‐funding   related  measures  were  up-­‐to-­‐date   (5   in   the  “resource   use”   and   2   in   “patient   care   processes”).   Later,   one   surgeon   told   me   that   he   only   ever  occasionally  viewed  the  WIES  activity  in  the  “resource  use”  quadrant  and  totally  ignored  the  others.    He  did  not  even  realise  the  balanced  scorecard  had  been  removed  from  the  intranet.        

The   reason   for   the  meeting   –   how   to  better   cascade   the  balanced   scorecard   from  a  high-­‐level  board  reporting  tool  –  certainly  provided  the  opportunity  to  initiate  conversations,  to  rank  and  order  important  measures  and  to   look  at  ways  the  accountant  and  clinician  worlds  would  come  together  and  be  represented.    

The   clinicians   began   by   arguing   that   they   did   not   always   understand   how   the   numbers   were  derived.  They  pointed  out  that  overhead  allocations  and  shared  costs  were  problematic.  They  tried  to  manage   the  allocations  between   themselves,  often   just  accepting  another   costs   centre’s   costs.  But  was  this  always  appropriate?  They  required  assistance  to  better  see  the   links  between  the  Casemix  dollar   accounts   and   the   patient   care   they   provide.     A   manager   of   the   critical   care   unit   (CCU)  explained  how  a  team  was  following  one  DRG  patient’s  care  throughout  their  entire  stay  in  the  CCU.  The   project   involved   counting   every   step   of   care   provided,   everything   from   bandages   to   drugs   to  nursing  hours.  They  wanted  to  determine  how  closely  the  government  DRG  funding  amount  matched  their  own  activity  costs  for  a  typical  CCU  patient.  This  was  an  interesting  project  and  everyone  was  keen  to  find  how  closely  the  funding  derivation  and  hospital  costs  matched.    This  would  provide  them  with  a  better  understanding  of  their  cost  objects  –  the  patients.    

A  document  presented  by  one  clinician  highlighted  ‘patient  separations’  as  the  significant  driver  of  costs  and  activity  in  the  hospital  (also  an  important  driver  of  the  Casemix  funding  system  and  one  of   the   “resource   use”  measures   of   the   balanced   scorecard).   She   explained  how  patient   departures  meant  that  beds  needed  to  be  cleaned,  new  patients  admitted  and  allocated  to  nursing  staff  on  that  shift.  Patient  admissions  required  preliminaries  such  as  detailing  a  paperwork  trail  of  patient  health  history  and  current  temperature,  pulse,  blood  pressure  readings  and  medications.  This  was  followed  by  doctor  visits  and  other  paperwork  associated  with  the  medical  admission  which  made  official  the  

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patient  treatments,  medications  and  other  tests  or  procedures  to  be  performed.  The  changeover  of  patients   needed   to   be   streamlined.   They   needed   to   quickly   link   the   patient   into   the   appropriate  clinical-­‐care  pathways,  particularly   if   important  time-­‐related  tests,  medical  or  operative  procedures  were  required  by  that  pathway  of  care.  

Another   clinician   explained   their   localised   budgeting   activities   in   relation   to   allocating   nursing  staff.  She  explained  how  some  clinical  units  managed  their  staff  really  well  while  other  clinical  units  found   it   really   difficult   to   keep   their   staff.   They   constantly  were   recruiting   casual   agency   staff   for  some  reason  or  another.  The  major  reason  given  was  related  to  the  workload  on  certain  wards  being  really  heavy.   The   clinical  wards  were  generally   structured  around   specific  patient  diagnosis  groups  and   the  wards   that  had  challenging  DRG  patients  were  often  harder   to   recruit   staff   to   (i.e.,  wards  where  patients  required  continual  care  –  drainage  bags  emptied,  chronic  lung  disease  patients  that  required  frequent  chest  physiotherapy  or  suctioning  of  their  lung  secretions,  heavy  lifting  orthopaedic  cases,  and  medical  wards  with  stroke  patients,  and  the  like).  Having  to  employ  agency  staff  increased  hospital   costs.  Her   spreadsheet   tried   to   find   relationships  between  heavy  patient   loads,   sick   leave,  nurse   turnover   and   long-­‐standing   nursing   employment.   It   connected   nursing   staff   with   ward   and  patient  DRG  requirements.  Although  she  developed  this  model  for  her  own  use,  she  wanted  to  see  it  more   widely   used.   She   later   spoke   to   me   about   how   she   was   working   with   the   accountants   to  develop  this  model  further.  

In  the  meeting,  the  accountants  and  clinicians  were  both  contemplating  how  they  might  better  work  together;  and  a  new  reporting  system  would  encourage  alignment  of  clinical  governance  goals.  Conversations  went   like  this:  “We  hope  that  …  we  will  start  the  amalgamation  …  start  devising  the  relationships  between  activity  data  and  the  financials  …  and  the  payroll.”  Interestingly  the  categories  of   concern   were   those   that   matched   the   clinical   cost   categories   underlying   the   DRGs   (underlying  Casemix).   The   accountants   became   increasingly   comfortable   with   the   individual   activities   the  clinicians   were   talking   about   because   they   recognised   and   linked   them  with   the   Casemix   funding  measures   and   summary   WIES   budget   results   they   delivered   every   month.   For   example,   patient  “separations”   as   high-­‐level   measures   for   Casemix   funding   purposes   and   the   underlying   clinical  activities   associated   with   patient   costs   categories   and   nursing   staff   movements   unfolded   as  important  measures  for  both  accounts  and  clinicians.    

Unexpected   funding   for  an  enterprise-­‐wide   resource  planning   (ERP)  and   financial  management  system  gave  accountants  and  clinicians  further  opportunity  to  see  the  big  financial  picture  and  drill  down   on   the   individual   department   details   they   desired.   The   management   reports   to   the   Board  would   benefit   from   this   ERP   system   detail   and   individual   needs   could   be   worked   out   between  accountant  and  clinician.  Everyone  was  happy.    

What   emerged   in   discussions,   however,   were   the   efforts   to   create   a   common   language   and  manage  business  responsibilities;  the  representational  activities  that  defined  the  balanced  scorecard  categories,  shifted,  to  more  closely  align  the  clinical  pathways  and  best  practice  guidelines  with  the  high-­‐level  Casemix  funding  model.      The   two  previous   stories   provide  moments   of   ordering   and   valuing.     The  Casemix,   health  economics   funding   model   provided   the   tool   for   accountants   and   clinicians   to   generate  calculable   values   that   could   then   become   audited   through   systems   such   as   balanced  scorecards.   The   symbolic   effectiveness   of   the   balanced   scorecard   was   debateable.    Nevertheless,  it  provided  a  system  of  exchange  and  highlighted  the  moments  of  hybridising  clinical   and   accounting   production.     In   the   following,   final   story,   a   moment   of   indexical  generalisation  is  offered.    In  this  story,  the  moments  of  exchange  can  be  recognised  as  on-­‐going   responses   of   ordering,   re-­‐ordering   as   a   response   to   Casemix   values   that   must   be  included.    The  parasitic  position  is  achieved  by  the  surgeon  in  his  demonstration  of  working  both   versions  of   representation,   in   a  way   that   value   and  order   emerge   simultaneously   as  informed  indexicality.      

 

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4.  Casemix  as  generative  simultaneous  negotiating:  working  position.  What  to  do  with  unexpected  Casemix  funds?    

In  a  general  surgeon’s  office,  adjacent  to  the  hospital,  the  surgeon  and  his  secretary  were  looking  at  his  public  patient  waiting   list.  He  explained  to  me  that  the  government  had  released  some  extra  Casemix  funds  enabling  additional  procedures  to  be  performed.  As  well  as  his  patient  waiting  list,  he  was   searching   through   his   diary   with   his   secretary   to   see   when   he   could   fit   in   two  more   theatre  sessions   before   the   end   of   financial   year.   It   was   only   weeks   away.   The   procedures   had   to   be  performed  in  this  financial  year.   I  watched  him  work  through  his  diary  to  find  two  free  mornings   in  which   he   could   operate.   He   regularly   operated   at   three   hospitals   (two   public   hospitals   and   one  private   hospital)   and   needed   to   fit   this   extra   operating   time   around   his   set   operating   hours   and  patient   consultation  clinic  hours  at  each  of   these  hospitals  and  his  own   rooms.  Once  his  diary  was  sorted  he  began   to  work   through   the  waiting   lists  with  his   secretary   to  determine   the  best  mix   of  general   surgical  procedures.  What  varicose  veins,  hernias  and  carpal   tunnels  would  he   fit   in  at   the  last  minute?  Running  his  finger  down  the  list,  he  said  –  “not  Mrs  Smith.  We  can’t  do  her.  She  needs  bilateral  varicose  veins.  They  are  too  messy.  Not  a  straight  forward  ligation  and  stripping.  I  can’t  fit  her   in,  given  the  time  and   funding  allotted”.  While  he  started  at   the  top  of   the   list  and  worked  his  way  down,  he  could  not  always  operate  on  every  patient  according  to  their  position  on  the  waiting  list.   Some   procedures  were   too   complex,   too   time   consuming   and   too   costly   for   the   few   hours   of  additional  theatre  time/funding  allocated.  For  some  procedures  certain  equipment  was  required  and  assistant  doctors  needed  to  be  coordinated.  These  additional  costs  were   included  in  the  DRG  which  made  the  procedure  costly.  As  he  ran  down  the  list,  it  was  a  balancing  act  of  his  availability,  Casemix  payment   versus   surgery   time,   DRG   complexity,   equipment,   assistance;   he   aimed   to   maximise   the  number   of   patient   treatments   for   the   allocated   funds.   This   was   a  moment   of   coordinated   clinical  governance   production.     He   was   consciously   and   confidently   negotiating   between   the   high-­‐level  ordering  system  and  the  clinical  pathways.          Analytic  typology:  explaining  the  three  representational  forms    

The  three  parts  of  Serres’  theory  of  relations,  production,  exchange  and  position  provides  a  language   to   begin   to   talk,   in   a   general   way,   about   the   mid-­‐level   practices   that   operate  between   the  high-­‐level   conceptualisations  and   the   individual   low-­‐level   clinical   governance  practices.    A  costing/caring  relationship  is  made  possible  through  prodution  and  exchange,  giving  birth   to  new  forms  of  collective  governance.    Exchange   is  enabled  by   the   third,   the  parasite   —bringing   power   to   the   governance   synthesis.       As   highlighted   earlier,   this  alternative  way  of   seeing   is   a  much   ignored   strategy   that   can  prevent   us   overlooking   the  relational  form  of  generalising.    The  theory  of  relations  offers  us  the  possibility  of  revealing  a  ‘mid-­‐level’  set  of  descriptors.    Not  the  specific  intuitive  commonsense  lower-­‐level  symbolic  descriptions  that  participants  might  offer  for  what  they  are  doing,  nor  the  large,  iconic  final  conceptual   accounts   ―but   a   mid-­‐level   form   of   categories   that   often   remain   silent   in  analysis.     These   mid-­‐level   descriptors   are   the   focus   of   this   proposed   representational  analytic  typology.        Iconic  representation  

The  opening  stories  show  the  CEO  and  the  nurse  as  a  producers.  The  nurse’s  attention  is  on  nursing  care,  not  really  aware  that  she  was  doing  “clinical  governance”;  the  nurse  was  doing  her  best   to   follow  well-­‐ordered   rules   taught  by   the   clinical  profession  about  best-­‐practice  pathways  of  patient  care   in  an  oncology  unit.  She  followed  routine  directions  to  assist  her  

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patients   with   meals   and   bathing;   taking   blood;   administering   drugs   as   ordered;   deciding  whether  additional  pain  relief   is  necessary  (panadeine  or  morphine?);  deciding  whether  to  inform  senior  clinicians   that   further   intervention  might  be  required;  performing  additional  or  routine  four-­‐hourly  observations  (blood  pressure,  pulse,  respirations  and  oxygen  levels);  completing   the   patient   chart   at   the   foot   of   the   bed;   recording   activities   of   note   in   the  patient   records.     Her   activities   might   be   viewed   as   factual,   value-­‐free   and   rational   in  following  the  clinical  and  Casemix  constitution.  The  nurse  begins  her  day  with  a  list  of  caring  duties  and  works  towards  her  pre-­‐defined  goals  to  deliver  high  quality  care  while  minimising  patient  risk.    A  linear,  means-­‐end,  production  of  care  according  to  the  implicit  care  pathways  as   universally   accepted   and   taught   by   the   clinical   profession.     The   list   of   tasks   can   be  converted   to   accounting   and   accountability   measures,   linked   to   the   Casemix   or   clinical  pathways  models   to  both  measure   (provide  a  value   for)  and  demonstrate  responsibility   in  meeting  expected  governance  ideals.    

 The  CEOs  attention  is  on  the  budgeting  details,  ensuring  governance  is  achieved  in  matching  the  hospital’s  Casemix  funds  with  planned  clinical  activity.  Working  the  nitty  gritty  details  of  the   accounts   in   his   daily   activities,   his   accounts   present   as   if   an   image   of   the   Casemix  accounting   icon.     Iconic   systems   are   designed   to   effect   coherence   by   maintaining   trust  between   the   competing  parties  and   can  only  be  possible  when  all   opposing   interests   (i.e.  economic,   social,   political   and   clinical   powers)   are   included   as   stakeholders.     In   meeting  Casemix  budgets,  the  CEO  realises  desired  regulatory  order  and  stabilises  future  funding  for  the   hospital.     The   success   of   this   clinical   governance   system   de-­‐politicises   and   rules   out  dissention  between  other  public  sector  facilities  as  well  as  the   internal  clinical  and  costing  environments.   The   two   members   of   this   clinical   governance   system   –   the   accountant’s  corporate   governance   technologies   and   the   clinician’s   operational   governance   practices   –  are   recognised   as   constituted   conformance-­‐performance   categories.   The  whole   of   clinical  governance  is  made  up  of  its  clinical  and  corporate  governance  parts.    In  this  form  of  iconic  generalising,  clinical  business  governance  and  accounting  corporate  governance,  two  equal  categories,  participate  as  one  to  effect  the  collective  sustainability  governance.    

 The  stories  have  helped  to  show,  that  in  a  similar  way,  Casemix  defines  the  abstract  quality  that  public  healthcare  provision  holds.    It  provides  a  moral  (clinical  governance)  prescription  of   “how  we   should   live”,   and   thereby   creates   social   order.   For   Casemix   (or   the   balanced  scorecard)   to   be   celebrated   as   iconic,   rigorous   collective   development   processes   with  opportunities   for   stakeholder   investment   must   be   provided.   With   this   form   of  representation  it  is  necessary  that  order  is  first  imagined  as  an  extension  of  the  wider  public  healthcare   provision   problem   at   hand,   followed   by   deductive   reasoning   and   related  research   that   tests   the   hypothesised   cause   and   effect   relations.     For   example,   a   general  reduction/increase   in   the   costs/patient   throughput   components   would   be   viewed   as   a  positive   contribution   to   the   efforts   to   negate   spiralling   healthcare   costs   and   at   the   same  time   improve   patient   access   issues   and   contribute   to  maintaining   order.   The   accountant  carefully  selects  and  determines  all  accounts   that  make  up  the  collective  governance   (i.e.,  WIES   targets,   patient   access,   patient   separations,   and  others   that   align  with   the   required  conformance   ideals).   The   nurse   is   given   ‘x’   number   of   category   ‘x’   patients   to   care   for;  follows   the  nursing  care  plan   that  prescribes  her   routine  activities.  Similarly,   the  balanced  scorecard  reporting  group’s  methodical  preparatory  work  of   interviewing  and  engaging  all  clinical  stakeholders  demonstrates  the  activities  to  rule  out  any  potential   future  dissent.   If  

 

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there   was   dissent,   this   would   be   attributed   to   the   underlying   theory   and   the   balanced  scorecard  model’s  ability  to  represent  collectively  agreed  clinical  governance.    Failure  would  require  more  theoretical  consultation.    

 Accounting  icons,  such  as  Casemix,  are  designed  to  effect  a  practical  equivalence  between  societal   care   and   the   monetary   economy   (Verran,   2009b).   The   two   conformance-­‐performance   realms   of   the   clinical   governance   system   are   recognised   as   two   distinct  members   that  collectively  make  up  the   icon.    Any   failure   in  clinical  governance  suggests  a  need   for   further  consultation  and  re-­‐evaluation  of   the  understood  state  of   flow  of  clinical  economic  activities.  The  result  is  a  reworked  icon  that  maintains  accounting  order.  

 Symbolic  representation  

In  the  second  context,  working  symbolically  is  about  participating  in  valuing,  not  ordering.  In  comparison   with   Casemix   accounting   as   an   extension   of   clinical   governance,   this   second  form  of  representational  foundational  logic  is  contingent  upon  multiplicity  as  constitutive  of  clinical  governance.  This  inductive  form  of  reasoning  is  more  open-­‐ended  and  exploratory  in  nature.     It   involves   qualitative   reasoning   about   the   value   of   health   care   provision.     The  clinical   and   accounting   categories   are   sectioned   into   a   plurality   of   units   and   then  calculated/added  to  the  collective  whole.  That  is,  imagined  as  a  nested  whole  with  a  single  value  (Verran,  2011:  8).8    The  valuing  of  the  multiple  categories  (financial  and  non-­‐financial)  is   aimed   at   representing   clinical   governance.   For   example,   we   could   take   the   individual  perspective  of  the  nurse,  Jack,  Jack’s  family,  the  accountant,  the  hospital  administrators,  the  government,   other   patients   with   similar   diagnoses   etc.   The   values   they   place   on   a  functioning   public   healthcare   system   add   together   to   represent   the   collective   clinical  governance.    The  context  generated  in  the  second  story,  the  balanced  scorecard  meeting,  is  about   developing   an   accounting   system   that   brings   all   these   interests   together   as   one  system.    It  would  be  a  “theoretically  justified  context  that  can  be  ratified,  possibly  by  a  vote,  at  a  meeting  of  constituent  interests  or  interested  parties”  (Verran,  2009a:  14).    Each  of  the  individual   perspectives   is   considered   as   separate   values,   loosely   held   together.   Including  myself  as  group  participant  and  observer,  we  were  all   important  parts  of  representing  the  collective.      

 The  balanced  scorecard  was  originally  designed  from  qualitative  reasoning  to  represent  the  multiplicity  of   stakeholder   values.  Added   together   the   values  were  designed   to   symbolise  the  public  hospital  context.  In  the  multiple  headings  and  boxes,  individual  parties  (patients,  clinicians,   accountants,   resource   providers)   can   see   where   they   are   positioned   in   the  performance  management  model.  Concerned   individuals  with  varying  voices  and   interests  are   presented   with   the   theoretical   guide   –   a   modelled   set   of   scenarios,   defined   in   the  balanced  scorecard  –  that  can  be  debated  according  to  their  varying  individual  background  expertise.   Any   ambiguity   leaves   “those  with   interests   unable   to   choose   and/or   unable   to  point   clearly   to  what   they   are   giving  up   in   the   event  of   a  move   to   compromise”   (Verran,  2009a:  14).    In  the  context  presented  here  the  scorecard  carried  the  flavour  of  a  segregated  

                                                                                                               8  The  difference  can  be  explained  with  numbers.    For  example,  “14”  can  be  seen  as  having  one  member  (1  x  14)  only  or  it  could  have  14  members  (14  x  1)  each  with  individual  values  (Verran,  2009b:  146–147).  That  is,  numbers  either  mark  or  commensurate  (Eseland  &  Stevens,  2008).    Icons  mark  while  symbols  commensurate.  Indexes  work  both  simultaneously.  

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collective. In  trying  to  develop  a  symbolic  representation  of  governance,  the  scorecard  was  vague  and  misunderstood  and  the  parties  that  it  was  trying  to  account  for  were  left  without  choice  or  a  place  in  the  system.  They  were  unable  to  see  what  was  required  of  them  in  the  call   to   achieve   collective   governance.   A   single   language   or   passage   to   clinical   governance  was  unable  to  be  negotiated  and  the  balanced  scorecard  could  not  generate  categories  that  connected  the  multiplicity  of  views.   It   required  too  much   interpretation  thus  undermining  its  ability  to  be  a  symbolic  representation  of  clinical  governance.      

Collectively  the  DRG-­‐  related  clinical  pathways  stood  as  an  extension  or  embodiment  of  the  iconic   Casemix   system.   At   the   same   time   the   pathway   activities   served   to   represent   the  individual  needs  of   the  accountant,   clinician,  patient,   relative,  hospital  management   team  and  government.    The  balanced  scorecard  and  clinical  pathways  were  parallel  technologies,  and  through  the  hospital  meetings,  brought  to  life  only  glimpses  of  momentary  connections.        Indexical  representation  

In   the   third   part   of   the   typology   the   connections   and   separations   between   the   two  (value/order)   processes   are   brought   to   the   foreground.     In   efforts   to   better  manage   the  boundary  between  the  ideal  and  the  political,  a  performative  space,  or  knowing  exchange,  is  evidenced.    Latour  refers  to  this  indexical  activity  as  “compositionism”:  

Compositionism  takes  up   the   task  of  searching   for  universality  but  without  believing  that   this  universality   is  already  there,  waiting   to  be  unveiled  and  discovered.…  From  universalism   it   takes   up   the   task   of   building   a   common  world;   from   relativism,   the  certainty   that   this   common  world   has   to   be   built   from   utterly   heterogeneous   parts  that  will  never  make  a  whole,  but  at  best  a   fragile,   revisable  and  diverse   composite  material.  (Latour,  2010:  3–4)  

While   Latour   explains   this   as   a   knowing   activity,   Verran   points   out   that   the   simultaneous  value/ordering   generalising   is   largely   unrecognised   in   moving   from   the   individual   to   the  collective.  A  range  of  healthcare  services,  which  can  be  valued,  somehow  becomes  a  whole:  “a  general  class”.  In  clinical  and  costing  activities  we  move  seamlessly  from  value  to  order.  Several   “services”   that   can  be   represented  and  valued  become,   in   the  next   sentence,   the  order  of  the  world  itself  (Verran,  2009b:  9).    In  the  stories,  the  nurse  and  the  accountant  do  not  recognise  they  are  working  indexically.    Like  most  of  us,  we  are  doing  it  all  the  time;  we  do  not  consciously  treat  accounting  and  clinical  practices  as  icons  or  use  them  as  symbols.    Working  to  suitable  targets  (blood  levels;  pain  levels;  time  frames)  are  not  necessarily  pre-­‐conditions  for  the  nurse’s  activities.  The  targets  are  there;  they  are  understood,  but  are  not  at  once  recognised  by  the  nurse  or  accountant  before  they  commence  their  daily  activities:  “instead   of   establishing   [targets]   before   you   engage   in   action,   you   keep   on   searching   for  [them]  while  you  act”  (Mol,  2008:  46).  The  CFO  accountant  is  working  value,  adding  services  and   costs   together  while   at   the   same   time   relieved  when   budgeted   targets   are  met   and  uncertainty  discharged.    The  nurse  in  the  first  story  is  deciding  at  every  encounter,  with  each  of  her  patients,  the  type  of  care  she  will  give.  The  nurse  observes,  chats,  makes  judgments  about  patients,  families  and  treatments:    

 

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“In  the  process  of  care  it   is  not  possible  to  put  the  facts  on  the  table  first,  to  then  add  the   values,   so   as   to   finally   decide   what   to   do.   This   is   not   to   say   that   facts   mould  themselves   to  our  wishes.   Instead,   the  point   is   that  practices   informed  by   the   logic  of  care  do  not  proceed   in  a   linear  manner.   Instead,  a  “sensible  course  of  action”  and  the  “normative  facts”  relevant  to  it,  co-­‐constitute  each  other.  Care  practices  are  resilient  as  well  as  adaptable”  (Mol,  2008:  45–46).  

In  working  indexically  we  unconsciously  attend  to  the  mess  of  the  real  and  through  this  co-­‐constituting  activity.    In  this  way  our  representational  generalizing  proceeds  simultaneously  (as  order  and  value).    We  might  ask  does   it  matter   that   this  practice   is  unrecognised,  and  that   sometimes   we   might   work   in   ordering   and   at   other   times   we   are   engaged   in  representing   order   in   a   specific   way   –   as   value?   I   suggest   this   dual-­‐generalising   property  does   matter.     If   we   make   efforts   to   recognise   and   highlight   this   unconscious,   but   very  important   generative   practice,   we   have   the   opportunity   to   better   intervene   in   clinical  governance  world  making.    Informed  good  faith  in  using  accounting  systems  is  in  part  being  familiar  with   the  difference   in  using   them  as   icons  and  using   them  as  symbols  and  also   in  recognising  opportunities  for  governance  improvements  (Verran,  2009a:  9).      

The  surgeon   in   the  third  story  was  working  knowing  exchange.    He  was  showing  a  certain  familiarity  in  using  the  Casemix  system  as  both  an  icon  and  symbol.  It  is  an  ordered  way  of  producing   care;   not   ordered   in   a   linear   fashion   and   not   a   producer   of   disorder,   but   an  ordered   co-­‐constitution   of   working   the   differences   between   the   two.   He   knowingly  managed  the  connections  between  the  two  generalising  logics  that  saw  clinical  governance  as   either   providing   order   in   the   health-­‐care   community   or   to   symbolise   order   through  accounting   for   the   multiple   values   associated   with   health-­‐care   provision.   That   is,   he  managed   the   value-­‐order   space   where   Casemix   operates   as   both   iconic,   generated   from  deductive   economic   logic,   and   symbolically,   generated   from   inductive   valuing.   In  working  Casemix  accounting  as  indexical,  he  is  addressing  the  governance  that  is  overlooked  in  iconic  numbers  and  denied  in  symbolic  numbers.    The  logic  of  care  is  a  logic  which  emerges  as  an  outcome  of  collective  participation  in  everyday  patient  care9.    

When  we  use  accounting  governance  frameworks  as  icons  we  overlook  the  symbolic-­‐valuing  potential.  We  develop  enterprise-­‐wide  models  that  manage  “nothing”  when  we  ignore  the  performative   space   (Power,   2009).   Qualitative   reasoning   is   overlooked   as   individual  expertise  and  contributions  are  cleansed  from  view.    This  is  because  the  big  picture  accounts  are   believed   to   capture   the   needs   of   all   stakeholders.   In  working   symbolically  we   equally  deny   the   iconic-­‐valuing   representations   of   political   reality.   The  way   to   represent   order   is  only   understood   through   the   processes   of   valuing   the   individual   contributions   to   the  collective.  Contingent  on  multiplicity  we  also  deny  the  experience  of  what   is  happening   in                                                                                                                  9  This  approach  to  theorising  is  one  that  is  open  to  multiplicity  (Mol,  2002;  2008).    For  example,  Mol  (2002)  shows  atherosclerosis  (a  medical  condition)  enacted  as  a  multiplicity.    Multiple  values.  For  the  pathologist  –  as  calcified  and  narrow  veins  “under  the  microscope”,  for  the  patient  –  pain  in  legs  on  walking;  for  the  doctor  –  a  weak  pulse  in  the  legs;  a  cloud  on  the  x-­‐rays  after  radioactive  dye  injection;  for  the  surgeon  –  blocked  vessels  to  be  unblocked;  for  the  exercise  therapist  –  a  disease  that  can  be  treated  with  exercise.  There  is  a  certain  “cohesion”  of  these  enactments  when  there  is  enough  correspondence  among  the  stories  that  everyone  can  be  said  to  be  talking  of  the  same  disease.    It  is  not  the  same  thing  i.e.  enterprise  governance  from  different  perspectives  (perspectivalism)  –  we  cannot  really  add  them  up  to  provide  a  single  value.    Each  story  enacts  its  own  reality.    The  indexicality  is  caught  in  the  moments  of  correspondence  among  the  stories.  

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the  here  and  now  of  corporate  reality,  we  deny  the  need  to  “wrestle  with  the  real”(Verran,  2009a:  9).    

For  indexical  exchange  to  come  to  life  and  to  stay  alive  there  must  be  an  elaborate  network  of   smoothly   functioning   institutions   with   trained   and   willing   workers,   complex   technical  procedures  and  material  arrangements  and  routines,  and  multiple  texts  of  differing  genres  to  be   interpolated.  As  always   in   indexical  exchange  there  are  surprises.  Surprise  can  occur  when   the   surgeon  manages   to   exceed   his   own   definitions   of  working   capacity,   given   the  system  constraints.    In  iconic  representation  there  would  be  no  surprise.  The  surgeon’s  work  would  be  overlooked,  or  cleansed  from  view,  as  it  would  be  assumed  in the  Casemix  model.    In   symbolic   representation   the   surprise  would  be  hidden   in   the   specific  ways   the   surgeon  goes  about  valuing  the  additional  Casemix  dollars.        When  we  acknowledge  the  capacities  that  accounting  framework  partiality  can  provide  and  that  the  governance  excess  can  be  fulfilled  through  varying  business  rituals;  this  is  where  we  find   exemplars   of   calculative   technologies   intervening   in   the   happening   of   the   real   –   and  vice-­‐versa  (Verran,  2009a:  11).    Through  applying  this  typology  to  our  research,  we  are  more  equipped  to  deal  with  the  unexpected  threat  to  enterprise  governance,  and  better  deal  with  the  perverse  effects  of  policy  choice.        Conclusion  

“Understanding  the  system  and  the  rules  of  parasitism  is  thus  more  important  than  giving  a  still  picture  of  reified  markets”  (Lépinay,  2007:  280-­‐281).  

 In   this  paper   I  have  developed  and  applied  a  typology  of  practices   in  order  to  explore  the  nature   of   collective   connected   governance   in   emergent   accounting   framings.     The   clinical  setting   provides   a   useful   setting   to   show   heterogeneous   individuals   constructing   the  collective   ideal   while   at   the   same   time   seeking   to   represent   this   world.     Following   from  Ahrens  and  Chapman  (2007),  I  contend  that  we  should  not  base  our  analysis  on  a  universal  rule   that   indicates   a   priori   what   should   be   produced.     Instead   we   should   follow   the   big  picture   conceptual   icons   and   their   low-­‐level   detailed   representations   as   they   emerge  together  and  multiply  as  performative  practice.     I  have  attempted  to  extend  the  notion  of  performative   practice   by   showing   accounting   practice   is   not   only   performed   by   situated  expects,   such   as   the   surgeon,   but   can   be   further   identified   as   performed   “informed  indexicality”.        The   typology  of  production,  exchange   and  position  helps   to   identify   the  accounting  parts,  the   situations   of   governance,   and   the   kinds   of   technical,   regulatory   and   property-­‐right  practices  that  shape  a  connected  enterprise  governance  reality   (Barry,  2001).  The  Peircian  notions  of   semiotic   and   the   conflation  of   the   iconic   and   symbolic   numbering   in   exchange  draw   our   attention   to   the   frequently   ignored   space   between   value   and   order.     The  generative,   indexical   form   of   generalising   is   the   everyday   performative   practice   of  contemporary  society,  made  visible   in  clinical  governance  practices.    But   this   is   the   riskier  context.  It  involves  mess,  confusion  and  noise.  Being  able  to  intervene  in  this  space  requires  value  and  order  generalisations   to  be  pushed   to   the  background,   so   the   indexical   context  can  be  brought  to  the  fore.  In  the  space  between  the  two-­‐way  conversation  Serres’  parasitic  

 

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logic   exists   as   the   simultaneous   negotiation.   Importantly   the   parasite   it   is   not   just   about  creating   a   system   of   relations,   through   production   and   exchange,   but   the   politics   and  mastery  of  that  system.  These  are  the  relations  of  domination  and  these  are  the  relations  that  must  be  understood,  not  after  the  fact  (when  governance  fails  or  invention  is  exalted),  but  while  they  are  happening.  This  is  the  point  when  practices  can  best  be  recognised  and  designated  good/bad  governance.      

 My  contribution  is  with  a  typology  that  reveals  the  indexicality  of  accounting  in  governance  model  creations.    I  contend  that  when  we  understand  this  mode  of  generalising  we  are  then  provided   with   the   opportunity   to   intervene   and   manage   the   position.   We   can   see   the  assortment  and  contingency  of  everyday  practices.  We  can  work  around  the  certainties  of  everything  that  is  known  through  a  normative  frame,  like  the  Casemix  methodology.      This   typology   of   representation   can   be   applied   other   contexts   where   value   gaps   are  contended.     For   example,   theorising   the   emerging   integrated   reporting   (IR)   and   the  heterogeneous   approaches   to   the   challenges   of   accounting   for   global   warming   (Eccles   &  Krzus,   2010).     The   typology   can  be  applied   in   risk  management  efforts  where  uncertainty  exists   between   qualitative   and   quantitative   analytics.     The   indexicality   of   accounting  numbers   would   be   interesting   to   explore   in   following   the   connections   and   separations  between  the  management  of  accruals  and  real  earnings  management.    This  typology  offers  the  ability  to  work  around  the  certainties  provided  by  detailed  relativist  framings  that  tell  us  what  we  ought  to  have  done  and  the  appropriate  action  that  should  have  been  taken,  given  the  circumstance   (Parker,  2012).  With   the  categories   that  provide  a  mid-­‐level  description,  we   can   then   recognise   that   constitutionalism   and   interference   go   well   together   and   we  need   both   to   feed   off   each   other.   An   informed   mode   of   indexicality   is   what   we   must  nurture,  rather  than  relying  on  general   insights  or  detailed  models  that  are  detached  from  actuality.      In   contemplating   the   organisation   of   accountability,   the   indexical   approach   offers   an  alternative   relational   approach   to   see  what   the   accountants   and   clinicians   and   corporate  employees  are  doing  about  accounting  for  governance  -­‐  a  way  of  studying  the  networks  of  relationships  making  up   the  parts  and  how  they  contribute   to   the  whole   -­‐   so   that  we  can  begin  to  think  about  how  we  might  do  it  differently.    This  framing  offers  an  important  way  to  intervene  in  governance  practices.    

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