Summary
Claire Cox, Patient Safety Lead at Kings College Hospital NHS Foundation Trust, shares a recent technique she used to explain the difference between 'work as imagined' and 'work as done'. Claire's example (a pathway for a patient coming to A&E, who also has a mental health issue) highlights the safety risks of competing guidance and the importance of co-production moving forward.
Content
The phrase work as imagined vs work as done is often used within patient safety but it's not always an easy concept to explain. I recently tried a new tactic to bring the realities of this concept to life, and show why it is so important to address these issues - in this case relating to a mental health pathway in A&E.
My aim was to explain how some of the policies we try to use don't actually work well together in practice when we have a patient come to A&E with a both a mental and physical health problem.
I started off by printing every piece of policy, guidance, standard operating procedure, related documentation on the trust intranet, HSIB reports, NICE guidance and anything I could find from the wider NHS. I pinned it across the walls in the meeting room. There were more than 150 items relating to how we should care for the patient in these circumstances.
We put the pathway that we 'imagined' at the top, like a process map along the wall. We then placed all of the policies and documents below the pathway at the relevant points. Then I got the staff to tell me what actually happens.
It became clear very quickly that the policies contradict each other. In trying to follow two policies, you couldn't actually adhere to either one properly. It was impossible for staff.
Once we did that exercise, participants in the room could see how the people writing policies did not perhaps understand how 'work is done'. So it was decided that any new policy that encompassed this mental health pathway for A&E would be co-written by patients, families and the staff doing the work. Importantly, this would include all staff involved - admin, clinical and management.
Once that had been written it would go through stages of testing to make sure it was working well and to incorporate necessary flex in the system when unexplained or unintended things happen. We would look at and test the vulnerabilities within that system or process.
The exercise took time and effort but it was an effective way to show people the challenges and barriers to safe care in a specific context. My advice to others trying to do the same would be to get it all out, expose it, make it as visible as possible.
Sometimes you have to be the one to put the writing on the wall.
Related reading
- Postcards from work: Exploring archetypes of human work through micro-narratives
- Work as is done, work as imagined
- Electronic observations – how safe is it?
- Proxies for work-as-done: a blog series by Steven Shorrock, Humanistic Systems
Share your thoughts
What did you think of Claire's example? Could you see this working in a different area of healthcare?Do you have any tips or techniques to share that could help others explain the challenges they face on the ground to large groups of people?
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