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
   

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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
   

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3. Image: Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/25wGrGQ
   

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4. Image: Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/MYAVK4
   

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5. How we
   work
   How we design &
   implement
   How we think
   What
   happens
   Influence
   Influence
   The fallacies of work as imagined | @stevenshorrock
   

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6. How we
   work
   How we design &
   implement
   How we think
   What
   happens
   Influence
   Influence
   The fallacies of work as imagined | @stevenshorrock
   

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7. The fallacies of work as imagined | @stevenshorrock
   

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8. How we
   work
   How we design &
   implement
   How we think
   What
   happens
   Influence
   Influence
   The fallacies of work as imagined | @stevenshorrock
   

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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
   

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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
    

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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
    “
    

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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
    “
    

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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
    

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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
    

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15. The fallacies of work as imagined | @stevenshorrock
    

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16. How we
    work
    How we design &
    implement
    How we think
    What
    happens
    Influence
    Influence
    The fallacies of work as imagined | @stevenshorrock
    

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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
    

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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
    

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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
    

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20. The fallacies of work as imagined | @stevenshorrock
    

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21. How we
    work
    How we design &
    implement
    How we think
    What
    happens
    Influence
    Influence
    The fallacies of work as imagined | @stevenshorrock
    

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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
    

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23. Image: Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/2bkA8HS
    

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24. enter your presentation title 24
    REQUEST FORMS
    RADIOLOGY
    bit.ly/TAOHW2
    

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25. 25
    CLAB
    CHECKLISTS
    bit.ly/TAOHW6
    

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26. RISK MANAGEMENT
    bit.ly/TAOHW2
    

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27. CARDIO-PULMONARY RESUSCITATION
    DO NOT ATTEMPT
    bit.ly/TAOHW2
    

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28. enter your presentation title
    COMPUTERISED
    MEDICAL SYSTEMS
    bit.ly/TAOHW5
    

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29. CARE HOME
    MEDICATION REVIEWS
    & REPEAT ORDERING
    bit.ly/TAOHW1
    

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30. enter your presentation title 30
    Photo: Marco Verch CC BY 2.0 https://flic.kr/p/QPTp5h
    DEFUNCT PROCEDURES
    bit.ly/TAOHW7
    

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31. Image: Steven Shorrock CC BY 2.0 www.bit.ly/TVOHW & www.bit.ly/TAOHW1
    www.humanisticsystems.com
    

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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
    

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33. or www.bit.ly/HindSightMagazine
    @stevenshorrock
    Download Free
    at SKYbrary.aero
    

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