The Fallacies of Work-as-Imagined

In this talk, I outline seven fallacies of work-as-imagined, concerning outcomes happen, how people work, how we design and implement, and how we think. A number of examples are given, provided by healthcare workers (see www.bit.ly/TAOHW1). The talk was given at HSJ Patient Safety Congress, 3 July 2019.

Transcript

1. Steven Shorrock Chartered Psychologist | Chartered Human Factors & Ergonomics Specialist 3 July 2019, Patient Safety Congress, Manchester @stevenshorrock | speakerdeck.com/stevenshorrock
2. “I feel there is an ever increasing disconnect again between what nationally is sometimes said to be going on and what people on the ground feel or see is going on.” Sir Robert Francis QC, 2017, HSJ The fallacies of work as imagined | @stevenshorrock
3. Image: Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/25wGrGQ
4. Image: Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/MYAVK4
5. How we work How we design & implement How we think What happens Influence Influence The fallacies of work as imagined | @stevenshorrock
6. How we work How we design & implement How we think What happens Influence Influence The fallacies of work as imagined | @stevenshorrock
7. The fallacies of work as imagined | @stevenshorrock
8. How we work How we design & implement How we think What happens Influence Influence The fallacies of work as imagined | @stevenshorrock
9. FALLACIES ABOUT OUTCOMES § The fallacy of difference § The fallacy of the first story (human error-as-cause) The fallacies of work as imagined | @stevenshorrock
10. We explain the unusual event by invoking the usual and proclaiming it to be different, when of course it is not. Instead, it is the obscure, accidental, and even random concatenation of normal disorders that produces a great event that we assume must have had great causes. Perrow (1984) Normal Accidents “ The fallacies of work as imagined | @stevenshorrock
11. The fallacies of work as imagined | @stevenshorrock Success and failure are derived from the same sources … bad events are not separate phenomena that can be eliminated by the use of some managerial or technological tool. Cook, Woods & Miller (1998) A Tale of Two Stories: Contrasting Views of Patient Safety “
12. The fallacies of work as imagined | @stevenshorrock Safety…is an emergent property of the ways in which the technical, individual, organizational, regulatory, and economic factors … join together to create the settings in which events—the best ones and the worst ones—occur. Cook, Woods & Miller (1998) A Tale of Two Stories: Contrasting Views of Patient Safety “
13. ‘FIRST STORY’ § Appears quickly after an event § High personalisation (sharp-end actors) § Low context § Low complexity § High newsworthiness § Appears easily preventable and fixable (with hindsight) The fallacies of work as imagined | @stevenshorrock
14. ‘SECOND STORY’ § Emerges slowly after long delay § Lower personalisation § Higher context § Higher complexity § Lower newsworthiness § No easy prevention or remediation The fallacies of work as imagined | @stevenshorrock
15. The fallacies of work as imagined | @stevenshorrock
16. How we work How we design & implement How we think What happens Influence Influence The fallacies of work as imagined | @stevenshorrock
17. FALLACIES ABOUT WORK § The mind projection fallacy (the ultimate WAI fallacy) § The fallacy of the system-as-designed § The fallacy of technical rationality The fallacies of work as imagined | @stevenshorrock
18. What is it about your work that others (outside of your profession) might find surprising, but that might be interesting or relevant to them? Or… What might you be reluctant to tell them? Tell me… steve.shorrock@gmail.com or @stevenshorrock
19. 1. Goal conflicts 2. Production pressures 3. Systems not-as-planned 4. Clumsy technologies 5. Procedural complexity 6. Barriers to feedback 7. Eroding defences 8. Adaptations 9. Compromises & Trade-offs 10.Drift The fallacies of work as imagined | @stevenshorrock
20. The fallacies of work as imagined | @stevenshorrock
21. How we work How we design & implement How we think What happens Influence Influence The fallacies of work as imagined | @stevenshorrock
22. INTERVENTION FALLACIES § The fallacy of the magic bullet § The fallacy of command-and-controlism reminders | policies | overproceduralisation | formification | clumsy automation | targetology | inspection visits | unjust sanctions The fallacies of work as imagined | @stevenshorrock BRITTLE STRATEGIES
23. Image: Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/2bkA8HS
24. enter your presentation title 24 REQUEST FORMS RADIOLOGY bit.ly/TAOHW2
25. 25 CLAB CHECKLISTS bit.ly/TAOHW6
26. RISK MANAGEMENT bit.ly/TAOHW2
27. CARDIO-PULMONARY RESUSCITATION DO NOT ATTEMPT bit.ly/TAOHW2
28. enter your presentation title COMPUTERISED MEDICAL SYSTEMS bit.ly/TAOHW5
29. CARE HOME MEDICATION REVIEWS & REPEAT ORDERING bit.ly/TAOHW1
30. enter your presentation title 30 Photo: Marco Verch CC BY 2.0 https://flic.kr/p/QPTp5h DEFUNCT PROCEDURES bit.ly/TAOHW7
31. Image: Steven Shorrock CC BY 2.0 www.bit.ly/TVOHW & www.bit.ly/TAOHW1 www.humanisticsystems.com
32. 1.Understand work-as-done (WAD) 2.Collaborate on work-as-imagined (WAI) 3.Co-design prototype work-as-prescribed (WAP) 4.Implement in work-as-done 5.Test WAI and WAP against WAD 6.Repeat above until WAI-WAP-WAD gap acceptable 7.Monitor WAI-WAP-WAD gap Image: Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/2ajEAFt DESIGNING FOR WORK-AS-DONE
33. or www.bit.ly/HindSightMagazine @stevenshorrock Download Free at SKYbrary.aero