O T H E R F E AT U R E S Bridging the Gap between Work-as-Imagined and Work-as-Done Ellen S Deutsch, MD, MS, FACS, FAAP, CPPS To improve the safety and quality of healthcare, we try to understand and improve how Editor, Pennsylvania Patient Safety Advisory healthcare providers accomplish patient care “work.” This work includes synthesizing Medical Director, Pennsylvania Patient Safety Authority information from a patient’s history and physical examination or from a handoff; per- forming tests or procedures; administering medications; and providing information so that patients can make the best choices for themselves. Sometimes this work flows very well and everyone is pleased with the results. Sometimes this work does not unfold in the way that was anticipated. Perhaps the patient’s condition is more complicated than usual, or perhaps a needed resource—a medication, a piece of equipment, available operating room time, or a consultant—is not readily available. Perhaps there is time pressure, or we encounter distractions and interruptions. Healthcare providers often complete tasks that are necessary for patient care despite obstacles in their path, and without necessarily reporting, let alone fixing, those obstacles. Efforts to improve healthcare work will not succeed without recognizing that there is a difference between a theoretical construct of “work-as-imagined” and the reality of “work-as-done” (see Figure). Work-as-imagined is the illusory ideal state. Hollnagel describes work-as-imagined as what designers, managers, regulators, and authorities believe happens or should happen, which becomes the basis for design, training, and control. In contrast, work-as-done is what truly occurs and what people actually do dur- ing patient care.1 Although a complete and perfect understanding of work-as-done is a worthy goal, healthcare delivery is a complex adaptive system that is in constant evolution with fluid, dynamic changes.2-6 Complete understanding is an unattainable ideal. Work-as- imagined provides information based on conceptual processes; it can offer a valuable hypothetical construct of the work in question, and may be used to develop theoretical concepts and generalizable guidance. Work-as-imagined may not reflect actual condi- tions that impact patient care at the “sharp end,” the point in patient care that directly impacts patients. However, exploring the gap between work-as-imagined and work-as- done does afford opportunities to look at work through a variety of lenses, each of which provides complementary information. Each lens has attributes and limitations; a preliminary exploration of several potential lenses, such as “work-as-documented” and “work-as-observed,” follows. With the blossoming of computer science, discrete event simulation can be used to analyze patient flow, predict demands for services, and mathematically model the impact of interventions on patient care processes. Standardized parameters for process components can be manipulated to calculate the effect of increasing patient volume or restructuring patient flow processes (e.g., change the triage process, add an ultrasound machine). Discrete event simulation can facilitate analysis of nonlinear interactions between variables and their intermediary agents; this could be considered “work-as-abstracted.”7 “Work-as-observed” occurs when care providers know they are being watched, whether informally by trainees or colleagues during patient care, or formally, such as dur- ing evaluations (e.g., certification examinations) or as participants in research. The well-known Hawthorne effect posits that participants modify their actions when they know they are being observed.8 As a consequence, the work that occurs during, for example, executive walkrounds, may not fully represent the work that occurs in normal situations. Documentation, fundamentally linked to patient care activities, serves many masters. Documentation is used to communicate meaningful patient care information, support Page 80 Pennsylvania Patient Safety Advisory Vol. 14, No. 2—June 2017 ©2017 Pennsylvania Patient Safety Authority Figure. Facets of the Work Process billing, and provide medicolegal informa- and the opportunity to document. When audits, and trigger tools9-12 relies on tion. The accuracy and completeness of a scribe is added to the documentation work-as-documented. “work-as-documented” may be impacted process, opportunities for incomplete Claims are written demands for com- by the skills and memory of the person understanding and miscommunication pensation for medical injury, which documenting, the ease or challenge of the may arise. Understanding work-as-done may be submitted by patients and their documentation process, and the temporal by using administrative databases, chart families because they have been advised distance between the patient care event Vol. 14, No. 2—June 2017 Pennsylvania Patient Safety Advisory Page 81 ©2017 Pennsylvania Patient Safety Authority O T H E R F E AT U R E S to sue; because they perceive physician patient care settings, provide a way to Because healthcare delivery is a complex dishonesty; because they seek informa- study and improve patient care processes adaptive system, understanding work-as- tion, resources for future medical costs, or while concurrently enhancing both team done is a daunting task, and no single revenge; or for other reasons.13,14 “Work- and individual patient care skills.17 A lim- perspective will provide the whole truth. as-claimed” is a lagging indicator, often itless variety of patient care processes can In an extensive review of the advantages reflecting occurrences that are several be simulated. Simulations may range from and limitations of different methods used years old.13,15 The relationship between simple tasks such as transporting a patient to monitor patient safety, Sun asserts, “. . . medical malpractice events and medical into a new patient care area or conduct- different methods for detecting patient malpractice claims is complicated and ing a handoff, to complex tasks such as safety problems overlap very little in the nonlinear.14 Some claims are without preparing to implement a new electronic safety problems they detect. These meth- merit, whereas the majority of patients health record module, implementing and ods complement each other and should who sustain a medical injury as a result of maintaining a patient on extracorporeal be used in combination to provide a negligence do not sue.13 membrane oxygenation (ECMO), activat- comprehensive safety picture of the health Simulation uses manikins or other equip- ing a protocol for massive transfusion, or care organization.”23 Recognizing the ment to replicate patient care experiences, conducting a disaster drill.18-21 “Work-as- attributes and limitations of each patient allowing healthcare workers to practice simulated,” including skilled debriefing, safety lens can help facilities develop a their skills without direct risk to patients.16 may come the closest to replicating more comprehensive and realistic under- Simulations conducted in situ, in actual work-as-done, particularly for uncommon standing of work-as-done, which can then events.22 inform efforts to improve patient safety. NOTES 1. Hollnagel E. Prologue: Why do our expec- 7. Day TE, Al-Roubaie AR, Goldlust 11. Murphy DR, Meyer AN, Bhise V, Russo tations of how work should be done never EJ. Decreased length of stay after E, Sittig DF, Wei L, Wu L, Singh H. correspond exactly to how work is done? addition of healthcare provider in Computerized triggers of big data to In: Braithwaite J, Wears RL, Hollnagel emergency department triage: a com- detect delays in follow-up of chest imaging E, editors. Resilient Health Care. Vol. 3. parison between computer-simulated results. Chest. 2016 Sep;150(3):613- Reconciling work-as-imagined and work- and real-world interventions. Emerg 20. Also available: https://dx.doi. as-done. Boca Raton (FL): CRC Press, Med J. 2013 Feb;30(2):134-8. Also org/10.1016/j.chest.2016.05.001. Taylor & Francis Group; 2017. p. xvii-xxv. available: http://dx.doi.org/10.1136/ 12. Westbrook JI, Li L, Lehnbom EC, Baysari 2. Vincent C. Patient safety. 2nd ed. Boca emermed-2012-201113. PMID: 22398851. MT, Braithwaite J, Burke R, Conn C, Day Raton (FL): CRC Press; 2010. 432 p. 8. Sedgwick P, Greenwood N. Understand- RO. What are incident reports telling us? 3. Dekker S. Drift into failure: from hunting ing the Hawthorne effect. BMJ. 2015 Sep A comparative study at two Australian broken components to understanding 04;351:h4672. PMID: 26341898. http:// hospitals of medication errors identified complex systems. Farnham (UK): Ashgate www.bmj.com/content/351/bmj.h4672. at audit, detected by staff and reported Publishing, Ltd.; 2012. long. to an incident system. Int J Qual Health 9. Classen DC, Resar R, Griffin F, Federico Care. 2015 Feb;27(1):1-9. Also available: 4. Deutsch ES. More than complicated, F, Frankel T, Kimmel N, Whittington JC, http://dx.doi.org/10.1093/intqhc/ healthcare delivery is complex, adaptive, Frankel A, Seger A, James BC. ‘Global mzu098. PMID: 25583702. and evolving. Pa Patient Saf Advis. 2016 Mar;13(1):39-40. http://patientsafety. trigger tool’ shows that adverse events 13. Studdert DM, Mello MM, Gawande pa.gov/ADVISORIES/Pages/201603_ in hospitals may be ten times greater AA, Gandhi TK, Kachalia A, Yoon 39.aspx. than previously measured. Health Aff C, Puopolo AL, Brennan TA. Claims, (Millwood). 2011 Apr;30(4):581-9. PMID: errors, and compensation payments in 5. Gell-Mann M. Complex adaptive systems. 21471476. medical malpractice litigation. N Engl J In: Cowan G, Pines D, Meltzer D, editors. 10. Mattsson TO, Knudsen JL, Lauritsen Med. 2006 May 11;354(19):2024-33. Also Complexity: metaphors, models, and real- J, Brixen K, Herrstedt J. Assessment of available: http://dx.doi.org/10.1056/ ity. Boston (MA): Addison-Wesley; 1994. the global trigger tool to measure, moni- NEJMsa054479. PMID: 16687715. p. 17-45. tor and evaluate patient safety in cancer 14. Rothstein MA. Currents in contemporary 6. Plsek PE, Greenhalgh T. Complexity patients: reliability concerns are raised. bioethics. Health care reform and medi- science: the challenge of complex- BMJ Qual Saf. 2013 Jul;22(7):571-9. Also cal malpractice claims. J Law Med Ethics. ity in health care. BMJ. 2001 Sep available: http://dx.doi.org/10.1136/ 2010 Winter;38(4):871-4. Also available: 15;323(7313):625-8. PMID: 11557716. bmjqs-2012-001219. PMID: 23447657. http://dx.doi.org/10.1111/j.1748- https://www.ncbi.nlm.nih.gov/pmc/ 720X.2010.00540.x. PMID: 21105950. articles/PMC1121189/. Page 82 Pennsylvania Patient Safety Advisory Vol. 14, No. 2—June 2017 ©2017 Pennsylvania Patient Safety Authority 15. Kreidler M. 2016 Medical malpractice 19. Patterson MD, Blike GT, Nadkarni VM. Reconciling work-as-imagined and work- annual report. Olympia (WA): Wash- In situ simulation: challenges and results. as-done. Boca Raton (FL): CRC Press, ington State Office of the Insurance In: Henriksen K, Battles JB, Keyes MA, Taylor & Francis Group; 2017. p. 143-52. Commissioner; 2016 Sep 1. 86 p. Also Grady ML, editors. Advances in patient 23. Sun F. Chapter 36: Monitoring patient available: https://www.insurance.wa.gov/ safety: new directions and alternative safety problems. In: Shekelle PG, Wachter about-oic/reports/commissioner-reports/ approaches. Vol. 3. Performance and RM, Pronovost PJ, Schoelles K, McDon- documents/2016-med-mal-annual- tools. Rockville (MD): Agency for Health- ald KM, Dy SM, Shojania K, Reston J, report.pdf. care Research and Quality (AHRQ); Berger Z, Johnsen B, Larkin JW, Lucas 16. Deutsch ES. Simulation in oto- 2008. S, Martinez K, Motala A, Newberry SJ, laryngology: smart dummies and 20. Patterson MD, Geis GL, LeMaster T, Noble M, Pfoh E, Ranji SR, Rennke S, more. Otolaryngol Head Neck Wears RL. Impact of multidisciplinary Schmidt E, Shanman R, Sullivan N, Sun Surg. 2011 Dec;145(6):899-903. simulation-based training on patient F, Tipton K, Treadwell JR, Tsou A, Vaiana Also available: http://dx.doi. safety in a paediatric emergency ME, Weaver SJ, Wilson R, Winters BD. org/10.1177/0194599811424862. PMID: department. BMJ Qual Saf. 2013 Making health care safer II: an updated 21965444. May;22(5):383-93. Also available: http:// critical analysis of the evidence for 17. Lockman JL, Ambardekar A, Deutsch dx.doi.org/10.1136/bmjqs-2012-000951. patient safety practices. Evidence report/ ES. Chapter 2.2. Optimizing education PMID: 23258388. technology assessment no. 211, Agency with in situ simulation. In: Palaganas JC, 21. Weintraub AY, Deutsch ES, Hales RL, for Healthcare Research and Quality. Maxworthy JC, Epps CA, Mancini ME, Buchanan NA, Rock WL, Rehman MA. Evid Rep Technol Assess (Full Rep). editors. Defining excellence in simulation Using high-technology simulators to 2013 Mar;(211):1-945. Also available: programs. Philadelphia (PA): Wolters prepare anesthesia providers before imple- https://www.ncbi.nlm.nih.gov/books/ Kluwer; 2015. p. 90-8. mentation of a new electronic health NBK133411/#ch36.s9 18. Geis GL, Pio B, Pendergrass TL, Moyer record module: a technical report. Anesth MR, Patterson MD. Simulation to Analg. 2017 Jun;124(6):1815-9. PMID: assess the safety of new healthcare 28207594. teams and new facilities. Simul Healthc. 22. Patterson M, Deutsch ES, Jacobson L. 2011 Jun;6(3):125-33. Also avail- Chapter 13: Closing the gap between able: http://dx.doi.org/10.1097/ work-as-imagined and work-as-done. In: SIH.0b013e31820dff30. PMID: Braithwaite J, Wears RL, Hollnagel E, 21383646. editors. Resilient health care. Vol. 3. Vol. 14, No. 2—June 2017 Pennsylvania Patient Safety Advisory Page 83 ©2017 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 14, No. 2—June 2017. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2017 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://patientsafety.pa.gov. 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