PATIENT SAFETY NOW

Healthcare is safer because of adaptation. We used to think workarounds were a problem, and maybe sometimes they are but most of the time they are evidence of expertise.

In my previous post, I talked about understanding everyday work. The reason why we need to focus a bit more intently on adaptation is that it probably is the most easily missed part of understanding everyday work. If you simply “go and see” and “have conversations”, you may hear about frustrations and good ideas, but you won’t necessarily recognise the countless small adjustments people make every day to keep the system working.

“What did you have to change, adjust, work around or do differently today to get the job done?”

For example:

• The patient arrives without the information they were supposed to have
• The equipment isn’t where it should be
• A colleague is unexpectedly absent
• The computer system is slow
• The clinic is running late
• Two competing priorities happen simultaneously
• Someone knows that the formal process won’t work and does something else

How did the person recognise what needed to be done, what did they do, why did they choose that option, and what made it possible?

That is where we might start to understand the real system. However, we talk a lot about narrowing the gap between work as imagined and work as done but we don’t really demonstrate how we might do that. It is also really hard for people to tell us that their work is different from what the policy or process says they should do.

The problem is that asking people to tell us about adaptation assumes they can safely identify it, articulate it and disclose it. In reality, they may not even think of what they do as an adaptation. They may think, “That’s just how we do it.” Or they may know perfectly well that it differs from the policy but be understandably reluctant to tell someone from the safety or governance team.

We could observe adaptions indirectly. I might pick some small area of work and see if I can follow it. However, I think we are missing the point if we are simply comparing what the policy says and then what people actually do, that feels very much like an audit of compliance. I don’t think it explores the countless small adjustments people make every day to keep the system working.

The question should never be, do people do what the policy says, it should be how does the system actually keep working, day after day, despite the difficult circumstances and situations people face. So how do we notice that someone might do anyone of the following:

• checks something before they start because they know it is often missing
• phones someone ahead of time because otherwise the patient will wait
• keeps an eye on a particular queue because the electronic system doesn’t reliably flag it
• asks a colleague to “just keep an eye on this” while they deal with something else
• remembers which member of another team is most helpful
• changes the order in which they do things because two demands have arrived simultaneously
• anticipates a problem before it occurs
• quietly fills a gap created by somebody else’s absence
• keeps information in their head because it isn’t easily accessible elsewhere
• switches between several systems to construct the information they need
• checks a colleague’s interpretation before proceeding
• delays something until the right person becomes available
• does something earlier than necessary because they know what will happen later
• notices that something isn’t quite right and intervenes before it becomes a problem.

None of those things necessarily represent deviation from a policy it shows how competent people get the job done.

As always it is best to see if we can fit it into something we are currently doing. Therefore we could use an incident as a way to understand adaptation. We already investigate these so we can use that to look at what were people doing to make this work before it went wrong, what adjustments were being made and what normally happens when this situation occurs. What we are trying to understand is what did people do differently this time and what usually prevents this from becoming a problem.

However we cant just rely on learning about adaption when it fails so occasionally the team needs to follow a small aspect of ordinary work. Not to compare it with policy but to simply ask, what are people having to do to make this work.

Existing activity	New question

Incident investigation

What adaptations normally help this work succeed, and what happened to them this time?

Incident review

What did people do to recover, compensate or prevent further harm?

Observation/go-and-see

What small adjustments do people make when nothing has gone wrong?

Complaints/concerns

What does this tell us about how the system actually behaves?

Good practice

What adaptations are making this team unusually successful?

Data/signals

Where might repeated variation suggest that people are constantly compensating for something?

We don’t need to create a new way of studying adaptation. We need to change what we look for in the things we already do