Caring for the institution: An ethnography of quality assurance policy in U.S. rural primary care

Based on mixed-methods, ethnographic research in a geographically isolated rural medical center in the upper midwestern United States, this paper explores the social implications of healthcare quality assurance policies highly reliant on managerial logics, including measurement and monitoring programs. Initially observed as expressions of apathy, throughout 21 months of observation in the medical center I increasingly witnessed tensions erupt due to divergent views of quality care. While explicitly intended to improve biomedical care, clinicians were quick to describe how quality assurance policies impeded their ability to provide high-quality primary care in this rural setting. This article theorizes ongoing tensions between patient care and institutional care as a key aspect of the observed organizational discord. The article concludes with recommendations for how to operationalize institutional care in this setting to respond to clinician and staff concerns about the unique challenges of this biomedical practice environment.