Directly linked to this way of thinking about safety is the view that what people do can be prescribed in some way; policies, procedural documents, guidelines, standards and so on. This view asserts that all the people need to do is adhere to them and care will be delivered in the right way, by the right people and safely.
There is often a huge difference between how the developers of these polices think and how the work is actually carried out. This is the difference between work as imagined and work as done. Why is this important? Because in healthcare people are held to account for these policies, when they may be unclear and unworkable. We need to really consider our approach to policies. This is summed up by Dekker and Conklin (2022) (pp. 47-48):
If the worker would simply follow the process nothing bad will happen, nothing bad could happen. That idea is crap. The idea that work is happening the way work is imagined is overly simplistic. It denies the reality that the world of work is a world filled with uncertainty, variability, and constantly changing organizational priorities and operational goals.
Performing work is not nearly as predictable as organizations desire work to be – and the act of wanting work to be predictable does not make the work stable or the statement true. Every worker, without fail every single worker, will tell you the work they do daily is different from the work the organization ‘thinks’ the workers are doing. Saying that every worker knows there is a difference between work as imagined and work as done is a bold statement. And yet, it is certain that this difference in work as done and work as imagined is real.
It is vital information for the organization to capture, and important to recognize. There is a difference between the work being done in the way organization imagines that work being done, and actually doing work. This difference is normal and the better (and sooner) the organization understands and embraces this difference, the better the organization will function as an effective and reliable facility.
Work as done is what people do to every day. In the main we are successful in our everyday work. This is because of our individual and collective expertise, our experience, and knowledge. We have an ability to adjust to the changes we face, to work around where we need to and to adapt. This is within in an environment of multiple shifting goals, constant variables, continuous and often unpredictable demand.
In healthcare it is rare that we can slow the demand down or prevent patients from coming in the door. Our work is done is impacted by limited resources (staffing, abilities, competency, equipment, procedures and time), and a system of constraints, punishments and incentives, which can all have unintended consequences. If you want to know how work is really done, ask the workers themselves. As Dekker and Conklin (2022 p 50) say:
The world’s leading experts in how work is being done in your organization already are on your payroll. You have within the walls of your facility the opportunity to know all there is to know about how work is being done. This information is well within your grasp; all you must do is ask the workers to tell you how the work is being done.
In summary, any normal day – a work-as-done day – people:
- Adapt and adjust to actually demand and change their performance accordingly
- Deal with unintended consequences and unexpected situations
- Interpret policies and procedures and apply them to match the conditions and patients
- Detect and correct when something is about to go wrong and intervene to prevent it from happening
Work as done is mostly impossible to prescribe, instruct, analyse, measure or even simulate precisely.
PATIENT SAFETY NOW 