Resilient Health Care, Volume 3

Reconciling Work-as-Imagined and Work-as-Done

Jeffrey Braithwaite, Robert L. Wears, Erik Hollnagel

• Publisher: CRC Press
• Year: 2016
• ISBN:
  9781315349589
• Edition: 1
• Topic: Business
• Subtopic: Service Industry
• Index: Business

This book is the 3rd volume in the Resilient Health Care series. Resilient health care is a product of both the policy and managerial efforts to organize, fund and improve services, and the clinical care which is delivered directly to patients. This volume continues the lines of thought in the first two books. Where the first volume provided the rationale and basic concepts of RHC and the second teased out the everyday clinical activities which adjust and vary to create safe care, this book will look more closely at the connections between the sharp and blunt ends. Doing so will break new ground, since the systematic study in patient safety to date with few exceptions has been limited.

Part I

Problems and Issues

Jeffrey Braithwaite, Robert L. Wears and Erik Hollnagel

Can an image of something, or a representation, or a plan of it, correspond to the thing itself? Alfred Korzybski once argued, no: the map is not the territory (Korzybski, 1931). The great philosopher Immanuel Kant also thought not. Although his theory of the world is much deeper and more extensive than we need here, for our purposes he made the claim that there are noumena (or abstract things that subsist but which we can never fully know) and phenomena (or the reality of things, displaying themselves to the perceiver through his or her senses). Essentially, Kant saw objects in two modes – things-in-themselves and things-as-they-appear (Kant, 1781, transl. Guyer and Wood, 1998). This vexed and vexatious idea has challenged philosophers before Kant. As Hollnagel points out in the Prologue, Plato's Theory of Forms postulated 2500 years ago a distinction between idealized abstractions that are in the mind, and direct knowledge known through the senses. In our domain of resilient health care, work-as-done (WAD) represents the observable phenomenon, or things-in-themselves, and work-as-imagined (WAI) represents the abstract noumena, or things-as-they-appear.

Although Korzybski, Plato and Kant had a different purpose than us (to do philosophy, compared with our more practical aims, to conceptualize ways to improve performance and safety), by way of analogy, this is the distinction that we are examining here. Our distinction is between the ‘imagined’ world of politicians, policy makers, managers, researchers and software designers and the ‘concrete’ world of doctors, nurses and allied health professionals, ward clerks and porters, each of whom experiences and contributes to care on those front lines. The former rely on their understanding or imagination of how work should or could be done to influence how work is done or can be done on the clinical front lines.

So the broad task we set ourselves, to reconcile views that imagine how work unfolds with those who do that work, has in different guises troubled intellectual giants for millennia. But before we can proceed very far in this excursion into the WAI–WAD spheres, we must begin to specify some of the problems and issues we encounter.

This brings us to the first five of our chapters, which collectively help us to secure a sound footing on which to base the rest of the book. We have grouped these under this first section, labelling it Problems and Issues. These chapters help tease out the scope of some of the challenges facing us, and the tests these set for the remainder of the book.

What types of problems and issues arise in these early chapters in clarifying the WAI-WAD distinction? A central one is whether we can, with purposeful effort, contribute to the task of actually conjoining the distinct WAI–WAD perspectives. That is firmly what the chapters in this section help us to think through. They range from Saurin, Rosso and Colligan (Chapter 1) and Sheps and Cardiff (Chapter 2), both of which help us to appreciate distinctions between attempts to create more Lean, streamlined and efficient health care in contrast to strengthening processes and resilient engineering perspectives in order to support naturally occurring flexibility and variation, to the role of patients in acting as a go-between across the WAI–WAD perspectives (Canfield, Chapter 3); to Nyssen and Bérastégui's Chapter 4, on the discrepancies and similarities between individual and systems resilience; and to the implementation of greater levels of resilience by harnessing Safety-I and Safety-II strategies, as presented by Chuang and Hollnagel in Chapter 5.

Altogether, these five chapters delve into these challenges in considerable detail. They provide some fundamentals for the chapters that follow. They do not identify every problem or issue at the nexus of WAI–WAD, of course. But they offer more than enough foundational work on which the later chapters build.

1

Towards a Resilient and Lean Health Care

Tarcisio Abreu Saurin, Caroline Brum Rosso and Lacey Colligan

CONTENTS

Introduction

Research Design

The VSM Model

The FRAM

Comparing FRAM and VSM

What Can FRAM Practitioners Learn from the VSM?

What Can VSM Practitioners Learn from the FRAM?

Lean or Resilience?

Conclusions

In this chapter, two approaches to managing health care systems are compared: resilience engineering (RE) and Lean production. Both approaches use modelling methods built on assumptions that influence the resulting analysis and any recommendations that are made. A comparison is made between representative methods of RE and Lean: the functional resonance analysis method (FRAM) and the value stream mapping (VSM) method, respectively. A study of the process of administering medications for patients hospitalized in an emergency department provides the empirical basis for this analysis. Reciprocal learning opportunities between the two methods are identified.

Introduction

Increasing economic, social and demographic pressures on health care organizations have fostered the adoption of process improvement methods found effective in other sectors. In particular, the use of Lean production, originally developed in auto manufacturing, has been embraced as an effective way to eliminate waste by concurrently minimizing supplier, customer and internal variability (Shah and Ward, 2007). The popularity of this approach has led to the evolution of “Lean health care”, and Lean is now considered an important tool for health care improvement (Kenney, 2011; Spear, 2005). Concurrently, the interest in RE has grown in health care (Fairbanks et al., 2014; Hollnagel et al., 2013). In contrast with Lean, RE research has shown the value of performance variability by front-line practitioners. This variability is seen as essential for the safe care of patients and for contexts that are replete with uncertainty (Sujan et al., 2015c; Nyssen and Blavier, 2013). In a cursory view, the two approaches seem to be in conflict, as they place different emphasis on variability and have different goals: the goal for Lean is efficiency and the goal for RE is safety. However, earlier studies have identified theoretical synergies between Lean and safety management approaches based on complexity insights, such as RE. For example, “use visual controls”, which is a core Lean principle (Liker, 2004), can be useful for resilience since it makes complexity visible and supports performance adjustment (Saurin et al., 2013). Moreover, both RE and Lean recognize there is a difference between work-as-imagined (WAI) and work-as-done (WAD). WAI is what designers, managers, regulators and authorities believe happens, or should happen. WAD is what actually happens in the workplace. Individuals and organizations are always adjusting to current conditions, constraints and the context of the moment. Thus, WAD reflects performance variability that underlies successful execution of “work in the wild” (Hollnagel, 2014a). Both RE and Lean recognize that the gap between WAI and WAD results from system complexity, rather than from faulty human performance (Hollnagel, 2014b; Liker, 2004).

In this chapter, a comparison is made between RE and Lean methods to describe sociotechnical systems (CSSs). The manner in which a system is described influences the analysis and recommendations made. The functional resonance analysis method (FRAM), which derives from the complexity and RE tradition (Hollnagel, 2012a), and the value stream mapping (VSM) method, which derives from Lean (Rother and Shook, 1998), are compared. FRAM has been the prominent tool for modelling complex CSSs in line with RE premises and provides insights as to how variability propagation affects performance. VSM identifies the extent to which the system is aligned with Lean principles and identifies processes that would benefit from Lean practices. A study of the process of administering medications in patients hospitalized in an emergency department (ED) provides the empirical basis for this comparison.

Research Design

A field study of medication administration was conducted in the ED of a major university hospital in the south of Brazil. Since the late 1970s, the ED has provided care in general practice, general surgery, gynaecology and paediatrics on a 24/7 basis. On average, 150 medical consultations are performed each day, totalling about 54,500 annual encounters. The ED has 275 employees distributed across 12 professional categories, and the physical environment is divided based on the level of patient acuity. The ED is part of the public health care network and is usually overcrowded. Although the official capacity is 41 adult and 9 paediatric beds, the number of patients is usually two or three times higher. Stretchers placed in corridors and hallways are commonplace, and management often uses local media to announce that the ED is closed due to overcrowding. The shortage of inpatient beds in the hospital is one of the contributing factors to overcrowding, and it is common that patients are cared for in the ED, frequently over several days.

The process of administering medications was selected for the FRAM and VSM comparison, because it is central to both patient safety, a core RE concern, and efficient supply of equipment and medications, a core Lean concern. This ED had previously been studied by the same research team and the work included a characterization of existing complexity attributes and the assessment of guidelines for managing complexity (Righi and Saurin, 2015). The VSM was applied first because the researchers were relatively more familiar with that method, rather than due to any identified relation of precedence. The researchers used a database developed in the previous work, which involved interviews with 18 members of staff, about 110 hours of observations of work at the frontline over a period of 6 months and the analysis of a number of documents, such as standardized operating procedures and reports of adverse events. This database supported identification of the ED functions, informal working practices and sources of variability.

The VSM Model

VSM was applied based on the guidelines proposed by Rother and Shook (1998), which involve four steps: (1) define a family of products or services to be mapped, (2) design the map of the current state, (3) design the map of the future/desired state and (4) develop an action plan to implement the future state. In this study, only (1) and (2) were addressed, as the further steps (3) and (4) are still pending agreement by ED top management. Two high-use medications (heparin and dipyrone) were selected as the family of products to be mapped (step 1), which means that for the purposes of the VSM these two medications could be regarded as a whole. A family is defined by shared characteristics of products or services, such as similar processing stages and processing times.

The map of the current state (step 2) was developed based on observations and informal conversations with employees. This map (Figure 1.1) has three broad zones. On the top, the information flows that support the physical flow of medications are represented. The boxes with borders in bold, on the top, refer to the agents exchanging information, and the nature of the information is between the arrows. Lines in zigzag mean electronic information flow, while straight lines mean physical flow of information. The icon on the top left represents the upstream boundary of the analysed system, which in the present case is the main warehouse of the hospital, from which the medications are transported to the pharmacy within the ED once a week. The icon on the top right represents the downstream boundary, which is the final destination of the medications. According to Figure 1.1, the medication can be administered either to the right patient, or if he or she...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Preface
• Editors
• Contributors
• Prologue: Why Do Our Expectations of How Work Should Be Done Never Correspond Exactly to How Work is Done?
• Part I: Problems and Issues
• Part II: Applications
• Part III: Methods and Solutions
• References
• Index