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The Fallacies of Work-as-Imagined

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.

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StevenShorrock

July 03, 2019
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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. Work-as-Imagined Work-as-Prescribed Work-as-Disclosed Work-as-Done 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 steve.shorrock@gmail.com @stevenshorrock Download Free at SKYbrary.aero