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  • Putting the writing on the wall: Explaining work as imagined vs work as done (by Claire Cox)


    Claire Cox
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    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.

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    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? 

    Share your thoughts by commenting below (sign up here first for free), or get in touch with our content team at content@pslhub.org 

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    Loved this, Claire! Well written, and an excellent demonstration of unintended consequences. Involving staff and families who are directly affected and have experience of using the service or care pathways, is essential. Let's not set up our staff and services to fail! Very proud of you and the direction you're leading!

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    What a great example of what is wrong. Very well done. I am in the process of designing a Roadmap and Framework to address this issue in the NHS. It will not be a quick fix as all processes in the NHS need to go through the process illustrated by you. It will also require recourses outside the NHS. But - it is a necessary and much needed activity. I have been working on this issue for 7 years, since retiring, and have not made much progress with the NHS. They need to understand that they can not make the necessary changes without professional help from proffecanals that know what they are doing. Key issues to be addressed include a just culture and staff welfare.

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    What a powerful way to demonstrate the value of patient experience. It will take bravery from colleagues to listen in order to learn how we can improve the way services are designed. Listening to colleagues providing direct care it is clear they daily have to use their judgement to navigate many conflicting guides and policies. This is a great approach to bridging the divide between reality and perception . 

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    Hi Claire. A great tactic that illustrates complex policies and procedures within healthcare process and to explain the concepts of safety 2 which focuses on the concept of work-as done versus work-as-imagined which reflects the approach to safety 1 for my day-to-day experience working as a family physician I can model what I actually do work-as- done tends towards simplification of policies and procedures The imaginary or the developed as standard that transform it into something like a simple flow chart for all those complex and many policies and procedures litriture .Despite this, I still believe in the need to find a tactic that accommodates the two methodologies as an entry point to simplify policies and procedures so that it achieves its end  goals in providing a safe healthcare service that preserves the patients safety and healthcare providers safety Within clinical human factors and health system redesign

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    Claire - well done for taking the initiative. It sounds like it was an excellent workshop. What are your plans now to deal with the existing policies, guidance, standard operating procedures? It sounds like there was consensus that they need to be improved.

    The process you describe for developing new policies would be great, but potentially onerous. Did the workshop give you any ideas about how it could be optimised to ensure documentation can be made available to support people when it is seen as necessary vs a requirement to get it as close to perfect as possible?

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    On 02/08/2023 at 00:39, tikena17 said:

    Hi Claire. A great tactic that illustrates complex policies and procedures within healthcare process and to explain the concepts of safety 2 which focuses on the concept of work-as done versus work-as-imagined which reflects the approach to safety 1 for my day-to-day experience working as a family physician I can model what I actually do work-as- done tends towards simplification of policies and procedures The imaginary or the developed as standard that transform it into something like a simple flow chart for all those complex and many policies and procedures litriture .Despite this, I still believe in the need to find a tactic that accommodates the two methodologies as an entry point to simplify policies and procedures so that it achieves its end  goals in providing a safe healthcare service that preserves the patients safety and healthcare providers safety Within clinical human factors and health system redesign

    It is that very tactic that I have been working on. There is no simple solution but never-the-less a solution is required and quickly.

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