Resilient Health Care: reconciling work-as-imagined

and work-as-done

Date: September 16, 2015 Melbourne, Australia

Jeffrey Braithwaite Professor and Director

Australian Institute of Health Innovation

Director

Centre for Healthcare Resilience and

Implementation Science

2

You

3

Fantasy Work

Plan

4

To do list

Tada list

5

When you get to the end of the day

you always find two things …

6

1. You didn’t accomplish everything

you imagined you would.

2. Your day wasn’t anything like

how you’d imagined.

7

8

This distinction

between

WAI

and WAD is …

everywhere

9

My own

expertise is in

health care, so

I’ll occasionally

use hospitals

as an example.

10

You’re not the only one

who imagines how work

is done.

11

Policy-makers, managers,

legislators, governments,

boards of directors, software

designers, safety regulation

agencies, teachers,

researchers.

Are you on

this list?

12

If so, you’re at the blunt-end of the system.

[Hollnagel, 2015]

The blunt end

tries to …

shape,

influence,

nudge

behaviour. 12

What they do

seems perfectly

logical, obvious

and feasible. 13

They design or apply policies, rules, protocols, procedures

and even laws—to make things safer for patients.

14

This manual contains 1164 regulations and guidelines spread

over 457 pages!

16

WAI—follow the rules!

The Department of Health

has over 3000 guidelines and

the National Institute for

Health and Clinical

Excellence has over 1000.

The NHS Library had a list of 152

publishers of guidelines and 17

references to guidelines about

how to develop guidelines! [Carthey et al. (2001) BMJ]

In health care, those

doing WAI have designed,

mandated or encouraged

a bewildering range of

tools, techniques and

methods, to reduce harm

to patients. 15

E.g., root cause analysis, hand hygiene

campaigns, failure modes effects analysis ...

16

And there’s lots of

others …

But the rate of

harm has flatlined

at 10%

17

Heart bypasses on

eight year olds, key

hole surgery, treatment

for HIV/AIDS. 18

But the rates

of harm

haven't

reduced far

enough 21

Meanwhile

work is getting

done, often

despite all the

policies, rules

and mandates 221

23

WAD—workarounds

Glove placed over a

smoke alarm, as it kept

going off due to

nebulisers in patients’

rooms.

Plastic bags placed over

shoes to workaround the

problem a of gumboot

(welly) shortage.

A leg strap holding an IV

to a pole, as the holding

clasp had broken.

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Doctors in Emergency Departments in a study:

• Were interrupted 6.6 times per hour.

• Were interrupted in 11% of all tasks.

• Multitasked for 12.8% of the time.

• Spent on average 1:26 minutes on any one task.

• When interrupted, spent more time on tasks.

• And … failed to return to approximately 18.5% of

interrupted tasks.

[Westbrook et al. (2010). Qual Saf Health Care]

WAD—fragmentation

So work-as-imagined folks

often have some sort of linear,

mechanistic view of the system.

21

Instead, health care is a

complex adaptive system

delivered by people on

the front line who flex and

adjust to the

circumstances. 26

And don’t deliver care in the

way blunt end

prescriptivists want them to.

27

The amazing

thing about

health care isn’t

that it produces

adverse events

in 10% of all

cases, but that it

produces safe

care in 90% of

cases. 28

Few people have ever looked

at why things go right so often

29

If I walk into a

public

hospital in

New South

Wales and

chat to the

front line … 30

What none of them know is that

there are 600 policies in operation

right now, meant to “guide” their

work.

31

Then when I observe

their behaviours and see

them taking patients’

histories, or giving out

medications, or doing

procedures, or taking x-

rays of patients, or

tending to their needs, or

caring for them … 32

I notice instead a lot of fraught, time-

pressed, relentlessly busy work going on

virtually across the entire shift.

29

It doesn’t look like

the pristine, logical

world dictated by the

work-as-imagined

proponents.

And it never, ever

unfolds like a policy

or procedure says it

should. 30

35

So, health care doesn’t look like this.

36

It looks like this.

And therefore

the only real

solution is to try

and reconcile

work-as-

imagined and

work-as-done. 32

A health system where

the work-as-imagined

policies, regulations,

standards etc are much

closer to an

understanding of how

work is actually done. 33

A message to blunt end people—

learn how work actually works.

34

A message to sharp end people—

work more closely with WAI people.

35

The bottom line?

36

In life, in marriage, in affairs of the

heart, in friendships, in international

relations, and in working

environments:

It’s always better to engage with your

partner. 36

Thank you for listening

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Recent Books

• Reconciling Work-as-imagined and Work-as-done

• The Sociology of Patient Safety

• Successful Health Care: the Experience of 60 Countries

• Gaps: the Surprising Truth Hiding in the In-between

• Culture and Climate in Health Care Organizations

• Resilient Health Care

• The Resilience of Everyday Clinical Work

• Healthcare Reform, Quality and Safety

Published In Press

2010

2013

2015 2015

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Contact

Jeffrey Braithwaite, PhD

Foundation Director

Australian Institute of Health Innovation

Director

Centre for Healthcare Resilience and Implementation Science

Professor, Faculty of Medicine and Health Sciences

Macquarie University

Email: jeffrey.braithwaite@mq.edu.au

Web: jeffrey.braithwaite.com

Web: http://aihi.mq.edu.au

Wikipedia: http://en.wikipedia.org/wiki/Jeffrey_Braithwaite