This is a blog which is part of a series of blogs linked to my second book which can be found here: https://www.amazon.co.uk/Implementing-Patient-Safety-Addressing-Conditions/dp/0815376863
The things that happen frequently in the daily activities of every day clinical work is coined by those that study human factors as work-as-done. In healthcare people adapt and adjust their actions and decisions according to the patients they are caring for, the conditions the work in, the people they are working with and situations they face. The combination of which are rarely if ever the same. Understanding how things are done when nothing goes wrong is a prerequisite for understanding how they may fail.
However, conventionally we assume that people will work as they are supposed to. The term work-as-imagined refers to the way people who regulate, inspect, set standards and guidance and design interventions may not understand what reality is actually like. There may be a considerable difference between what people are assumed or expected to do and what they actually do. If there is a difference the people involved are accused of non-compliance, violations or performance deviation.
The policy could turn out to be unworkable, incomplete or fundamentally wrong. The incongruence makes it hard for frontline staff to implement things they are being told to do resulting in frustration and workarounds. The unintended consequence of this is that it triggers a degree of initiative fatigue or fatigue in relation to initiatives that seem misaligned with the goals of their day to day work creating a chasm between the leadership and frontline of organisations.
When we fix the wrong thing the same problems continue to surface. It’s costly and demoralising.
Guidance in the form of standards, procedures, checklists, alerts, interventions and policies are necessary in healthcare and here to stay. However, if there is a serious attempt to make rules for every aspect of the work in healthcare, people will soon realise that it is impossible to explain every single action for every possible environment and situation.
Work as prescribed is when we set clear rules and detailed instructions. In the three models of safety I shared the work of Vincent and Amalberti who assert that there are some specialties such as radiotherapy, chemotherapy, medication administration (the ultra-safe) when the gap between work-as-done and work-as-prescribed needs to be as narrow as it possible could be. This is where it is vital that the prescribed practice matches reality and is constantly reviewed to ensure that it remains so. Some forms of prescribed work become defunct but are still officially in place. Some forms of prescribed work have drifted into mythology with people convinced that they are expected to work in a certain way which has in fact never been prescribed.
We need to ensure the guidance matches as close as possible to day to day activity, is intuitively easy to do and in fact enhances and optimises everyday behaviour. Healthcare delivery and healthcare treatments are changing all of the time and people’s memories become distorted. Even if the guidance (of whatever form it takes) is developed by people who used to be those that were at the frontline and immersed in the work-as-done, the moment they step out of that area they start to become removed from it.
Most work is impossible to prescribe exactly. Work is also a combination of experience, expertise, clinical judgement and know-how. Not everything we do can be written down in detail. In this case the guidance is more likely to work if it is written in general terms rather than the fine detail which may not quite fit with reality. It is important to ensure that the guidance is constantly reviewed to ensure that it is still up to date and also still workable.
Work-as-disclosed is how people describe what they do. However this may not always be what is actually done. For many reasons, it may be the partial truth. This may be because:
- explaining every little detail would be too tedious
- we do things automatically and we may forget some of the details when we come to explain it
- we may tailor it to the audience and when we come to explain it we do it too simply
- we say what we want people to hear
In a culture of fear and when being scrutinised we may ‘just tell people what should happen not what does happen’ or ‘simply tell people what we think they want to hear’. Equally everyone involved will have their own unique experience and account of what happened, which may differ and even be contradictory. No one will be either right or wrong just different depending upon what they recall, what part they played or their experience. Bringing together all the truths provides a fuller picture.
The fact it may not be disclosed relates to the fear of what people will do and say if they realised what actually happened on a day to day basis to get things done. You can only ask the question if you have a culture where people will not feel judged and will feel that someone cares even if they answer no. You can only ask the question if you are willing to listen, learn and then figure out what could be don’t to help people wash their hands more often.
Why is it important to narrow the gap?
It is important to narrow the gap because safety must be based on an understanding of work as done, an understanding of the everyday. Constraining performance adjustments or shifting peoples actions towards a working practice which does not fit with their everyday will make work difficult or impossible and even lead to failure. Whenever something goes wrong it rarely if ever happens for the first time. Whatever happens has happened or been done many times before and will in all likelihood be done again many times in the future. It is also true to say this applies for when something goes right. It has been done many times before and will be done many times again for the simple reason that it works.
Steven Shorrock – via