Table Of ContentResilient Health Care
V O L U M E 3
Reconciling Work-as-Imagined and Work-as-Done
E D I T E D B Y
Jeffrey Braithwaite • Robert L. Wears • Erik Hollnagel
Resilient Health Care
VOLUME 3
Reconciling Work-as-Imagined and Work-as-Done
Resilient Health Care
V O L U M E 3
Reconciling Work-as-Imagined and Work-as-Done
E D I T E D B Y
Jeffrey Braithwaite
Robert L. Wears
Erik Hollnagel
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Contents
Preface ....................................................................................................................vii
Editors ......................................................................................................................xi
Contributors .........................................................................................................xiii
Prologue: Why Do Our Expectations of How Work Should Be Done
Never Correspond Exactly to How Work Is Done? .......................................xvii
Part I Problems and Issues
Jeffrey Braithwaite, Robert L. Wears and Erik Hollnagel
1. Towards a Resilient and Lean Health Care ...............................................3
Tarcisio Abreu Saurin, Caroline Brum Rosso and Lacey Colligan
2. The Jack Spratt Problem: The Potential Downside of Lean
Application in Health Care – A Threat to Safety II ...............................19
Sam Sheps and Karen Cardiff
3. Recovery to Resilience: A Patient Perspective ........................................27
Carolyn Canfield
4. Is System Resilience Maintained at the Expense of Individual
Resilience? ......................................................................................................37
Anne-Sophie Nyssen and Pierre Bérastégui
5. Challenges in Implementing Resilient Health Care .............................47
Sheuwen Chuang and Erik Hollnagel
Part II Applications
Jeffrey Braithwaite, Robert L. Wears and Erik Hollnagel
6. Exploring Ways to Capture and Facilitate Work-as-Done
That Interact with Health Information Technology..............................61
Kazue Nakajima, Shinichi Masuda and Shin Nakajima
7. Resilience Work-as-Done in Everyday Clinical Work ..........................71
Andrew Johnson and Paul Lane
v
vi Contents
8. Understanding Resilient Clinical Practices in Emergency
Department Ecosystems ..............................................................................89
Jeffrey Braithwaite, Robyn Clay-Williams, Garth S. Hunte
and Robert L. Wears
9. Reporting and Learning: From Extraordinary to Ordinary .............103
Mark A. Sujan, Simone Pozzi and Carlo Valbonesi
10. Reflections on Resilience: Repertoires and System Features ............111
Richard I. Cook and Mirjam Ekstedt
11. Power and Resilience in Practice: Fitting a ‘Square Peg in
a Round Hole’ in Everyday Clinical Work ............................................119
Garth S. Hunte and Robert L. Wears
Part III Methods and Solutions
Jeffrey Braithwaite, Robert L. Wears and Erik Hollnagel
12. Modelling Resilience and Researching the Gap between
Work-as-Imagined and Work-as-Done ...................................................133
Janet E. Anderson, Alastair J. Ross and Peter Jaye
13. Simulation: Closing the Gap between Work-as-Imagined
and Work-as-Done ......................................................................................143
Mary Patterson, Ellen S. Deutsch and Lisa Jacobson
14. Realigning Work-as-Imagined and Work-as-Done:
Can Training Help? ....................................................................................153
Robyn Clay-Williams and Jeffrey Braithwaite
15. Resilient Procedures: Oxymoron or Innovation? .................................163
Robert L. Wears and Garth S. Hunte
16. Conclusion: Pathways Towards Reconciling WAI and WAD ...........171
Jeffrey Braithwaite, Robert L. Wears and Erik Hollnagel
References ...........................................................................................................179
Index .....................................................................................................................199
Preface
Jeffrey Braithwaite, Robert L. Wears and Erik Hollnagel
Resilient health care (RHC) focuses on everyday clinical work (ECW) – which
means work as it unfolds in practice – accomplished by those working at the
sharp end of the system in direct contact with patients. But ECW takes place
in conditions that are significantly shaped by those at the blunt end of the
system, distanced from the sharp end in both time and space. Their aim is to
ensure the safety and productivity of ECW by the way they prepare, orga-
nise and manage the conditions in which work takes place. Because today’s
health care takes place in complex sociotechnical systems, ECW relies on
workarounds, trade-offs and adjustments in order for everyday activities to
succeed.
In today’s health care environment, with its complicated relationships,
technologies, services and practices, it is inevitable that work-as-done (WAD)
differs from work-as-imagined (WAI). ECW will therefore always be differ-
ent from that which is intended, planned and prescribed. Although the dif-
ferences usually are not dramatic, they may nevertheless at times lead to
problems. In order to ensure that health care is resilient, it is therefore neces-
sary to continuously realign the two perspectives on work, rather than insist
on one being right (usually WAI) and the other being wrong (usually WAD).
That is the precise point where this book hopes to make a contribution.
Before we introduce the book, however, we should provide some context for
both the series to which it belongs, and for the background that has brought
us to our current position.
The publication of this volume completes a serendipitous trilogy of work
in RHC. To understand how this happened, we need to recognise the links
to ideas that existed long before the current thinking about resilience and
resilience engineering (RE) began in the 1970s. These ideas, as Hollnagel
suggests in his Prologue, may even be glimpsed in Plato’s stories, through
Socrates’ narratives, of the allegory of the cave – in which there are shadow-
like appearances of people and animals on the walls of the cave (for us, WAI),
and realities beyond the cave (for us, WAD). We have applied the modern
version of these ideas to our enduring interest: the contemporary health sys-
tem, replete with its complex idiosyncrasies, ambiguities, conflicting goals,
socio-professional divides, competing interests, multiplicity of treatments,
care models, services, staff and subsystems and enabling and constraining
mechanisms.
vii
viii Preface
RE pointed out that in the past, systems and safety experts had been pre-
occupied with a “find and fix” perspective, focusing on things going wrong
at the expense of understanding the whole gamut of performance. To break
free from that, RE advocates that it is more important to understand how
things work than how they fail, in order to be able to improve performance
and increase the number of acceptable outcomes.
In our series of RHC books, we also recognise a link between the three
volumes. In the first volume, Resilient Health Care (Hollnagel et al., 2013), we
set the scene, and teased out the kinds of circumstances in which people on
the front lines of care adjust, flex and accommodate in executing their func-
tions as doctors, nurses and allied health professionals, and we glimpsed
the relative contributions of both this sharp end and the blunt end to sus-
taining performance. Taking a lead from work that culminated in Hollnagel
(2014b) the idea of two kinds of safety (Safety-I, aiming to reduce harm by
trying to make sure things do not go wrong) and its reciprocal (Safety-II,
aiming to improve the ability to succeed, and striving to make things go
right) was teased out. The second volume, The Resilience of Everyday Clinical
Work (Wears et al., 2015), concentrated much more directly on the front-line
activities, and analysed many different settings – wards, departments, emer-
gency care, critical care, operating theatres and community pharmacies, for
instance – to reveal much more than was previously understood about the
activities of those making such adaptations over time.
To complete the trilogy, we need to appreciate further the relationships
between those who fund the services and specify the way care should
unfold, and those who deliver the services in real time. In what follows,
after this Preface from the three editors and a Prologue from Hollnagel, we
begin the task of deepening our understanding of these relationships and
arrangements.
To do this we have divided the chapter contributions into three sections.
The first, Problems and Issues, covers topics as wide ranging as what resilience
is and how people can absorb the ideas it has spawned, to the patient’s role in
creating resilient health care (and perhaps acting in a bridging role between
WAI and WAD), to Lean approaches to improvement contrasted with resil-
ient approaches. These initial chapters establish a platform for the work that
follows.
The second section, Applications, shifts the emphasis. We present here
an intriguing array of contributions articulating the ways we might bring
together, or at least refine our appreciation of, WAI and WAD. The chap-
ters touch on topics including WAD and health information technology, and
the alignment of WAI and WAD in operating theatres. Other applications
include how to model and represent WAD. Specific applications include
manifestations of resilience in emergency care, and how systems that
learn from everyday activities can contribute to narrowing the WAI–WAD
nexus. Contributions also reflect on the point that power is never far away
from the WAI–WAD paradigm, and, closely related to this, recognise that
Preface ix
policymakers, managers, clinicians, patients and researchers not only have
differing perspectives on RHC, but make different demands on the system
that expresses it.
Armed with the information from the first and second sections readers
will in the third section, Methods and Solutions, learn what to do with this
information. This section distinguishes itself by advancing work contribut-
ing to bridging the gap between the WAI and WAD worlds: essentially, by
researching, modelling or simulating activities; or by purposefully design-
ing greater levels of resilience into the care processes wherever possible in
order to strengthen rather than perturb them; or to train blunt- and sharp-
end people in the utilities and capacities of resilience thinking.
One thing remains clear. It is not possible to provide a complete descrip-
tion of everything that goes on in a complex workplace. In that respect, WAI
inevitably falls short of the aims it has for streamlined, effective and effi-
cient work to unfold in pre-specified ways. But neither is it possible simply
to expect front-line operators to get on with the job without providing them
with resources, supporting systems and guidelines for performing. Both
WAI and WAD are therefore essential: we simply cannot have one without
the other.
Our core message is that whatever our vantage point, we ought not cling
stubbornly to only one view of the world and insist that it is the right one.
Whether we identify mostly with a regulatory-policy, managerial, top-down,
blunt-end perspective, or whether our world is steeped in a front-line, practice-
centric, bottom-up, sharp-end perspective, having only one standpoint is
both insufficient and dangerous. Care needs to be planned, managed and
funded. It also needs to be rolled-out, executed and enacted. It is when plans
meet reality that the two worlds meet, are able to be reconciled and care is
resilient. So it is in the synergy between the two that our hopes for better,
more responsive, resilient, safer care must be based. The tensions between
WAI and WAD, between standardisation and contingency, between sharp-
end and blunt-end interests, cannot be resolved, but must be actively and
creatively managed, case by case, through judicious actions by the parties
involved.
