Rapping your way to better care: why understanding work matters

This is article twenty-one in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

"It’s like improving a horse’s performance without speaking to the rider,
or making a car go faster without considering the driver,
or improving veterinary care without involving the providers."

I didn’t mean for this article to start as a rap when I sat down to write it, yet here it is!  I use the word ‘rap’ loosely, but it was fun to read it hearing Lin-Manuel Miranda’s voice in my mind (creator of the musical Hamilton).  I then thought maybe I should be a bit more serious but decided against that – rhyming helps me remember things and one of the fundamental concepts in improvement is understanding work as done vs work as imagined. 

In the discipline of human factors, we are tasked with understanding and evaluating all the things that affect people at work by considering both the mental and physical characteristics of people, the organisation, and the wider profession in which they work. We apply what we learn to the design of tasks, jobs, equipment, work environments, and systems of care to make life better for people at work and make it easier to deliver the right care for the patient¹.

What do I need to know about work?

Steven Shorrock, Human Factors Specialist, describes four varieties of work²:

• Work as imagined describes the assumptions we can make about how work should be done.  When we think about work, we typically think about what we do. But when we think about what we do in relation to what others do, this is work as we imagine it to be. ‘These are the steps I would take to ensure the first surgical patient is on the table by 9 am.  I assume that’s what others must do too.’
• Work as done is what people actually do. It is difficult to describe precisely as work as done responds to the immediate demand, such as the needs of the client and patient, staff shortages and high workloads, which can mean adjustments and compromises are made.  ‘I would usually take these steps to have the first surgical patient on the table by 9 am, but because we are close to a local school, often the clients are caught in traffic, so I take these additional steps to make it more likely to happen.’
• Work as disclosed is how we talk about work, it’s what we tell people we do but may not actually be work as done.  What we disclose is dependent on who we are talking to and if we fear any consequences.  Building trust will help people feel comfortable with disclosing how work is actually done.   ‘I am not following usual protocol, so I am not sure if I will get in trouble for taking these additional steps. Perhaps I shouldn’t mention them.’
• Work as prescribed is how work is formalised, and can take shape in the form of regulations, policies, standards, checklists, job descriptions, etc. While it tries to encompass work as imagined-done-disclosed, work as prescribed is often done by more senior members of an organisation or professional bodies, who sometimes have little or no contact with the frontline and may have never performed the task. Therefore, work as prescribed sometimes does not encompass work as done, or work as disclosed. ‘The first surgical patient of the day must be on the table by 9 am by following these steps.’

So why is understanding work important? 

Whenever we are trying to improve something, we must always start by trying to gain a full understanding of the problem, or opportunity in front of us.  We can only truly understand by appreciating how work is done by building trust and learning from the people who are doing it.  Looking at the definitions of work above, we can see how this might be problematic.  This does not imply that a type of work is better than the other, as there will be truth in all of them.  What is important is we take time to understand the system considering the varieties of work, so that we can work together to improve it.

Had enough theory? Let’s apply it to a real-life example.

Saving time is a hot topic right now, as we find ourselves having to navigate doing more work, possibly with fewer people. Improving efficiency translates into using the team’s time and experience most effectively, while safely working toward the right outcome for the animal.

Let’s narrow the scope to improvements in the theatre. There are countless benefits in running an efficient operating theatre, focused on an agreed plan which can be adjusted if needed, having the right equipment for the job, people getting lunches, and reducing stress for the animals in our care.  People working to their strengths, maximising the time available to them to ensure clients have access to care, while allowing the team to give the care that is needed. 

While I think we can all agree improving efficiency is a good idea, it’s not always easy to do. People may not feel they can affect change, so the system doesn’t improve. A well-meaning person may see this and think to themselves, ‘well I wouldn’t do it that way, they need to be doing it this way’. If we try to make changes with this approach, we risk turning people off and contributing to feelings of burnout. It’s also unlikely we will improve the system because we don’t understand work as it’s being done and are only operating from a work as imagined point of view.

Instead, we can take our experience, curiosity, and an open mind to the problem.  Work with the team to understand how work is done and how they respond to increasing demands, adjustments they make, and how they work around parts of the system that may not make sense to them.  Encourage the team to come up with ideas to test, to meet the goal.  Ensure their feedback is heard when testing change ideas, to know whether the goal is being met, with the meaning in which it was intended.

How do we discover work as done vs work as imagined?

Hopefully I have convinced you that peeling back the layers of work as done vs imagined is important.  But how do you go about it?  Process mapping can help us here.  Get a stack of Post-it^® notes and take some time with the team to map out every step in the system you are trying to improve.  In our case, theatre efficiency.  Map out the process from the point the client is considering surgery to the point the animal is discharged – a Post-it^® for every step.  (I like using Post-its^® because they can be easily moved around if you forget a step!)  Do this for how you imagine the system to work.  Do it again for how it really works.  Where are the differences?  What are the gaps that we need to close? Where can efficiencies be gained?  Doing this is a real learning opportunity; it helps people discover how others view the work and highlights areas for improvement.  Convert this into your ideas for change.

Questions to help you analyse your process map³

• How many steps are there?
• How many hand-offs are there? Are they necessary?
• Can the task be carried out by one person instead of several?
• Is there any duplication of work?
• Are there any bottlenecks?
• How much error correction is being carried out?
• How long does each step take?
• What is the time between each step?
• Which tasks help to achieve the purpose and which do not? 
• Are we doing the right things in the process?
• Are we doing things in the right order?
• Is the right person doing it?
• What information do we give clients at what stage, and is this useful?
• Should some tasks performed as part of another process be performed here?
• Where are the points that have a negative effect on the patient?

"It’s like improving a horse’s performance without speaking to the rider,
or making a car go faster without considering the driver,
or improving veterinary care without involving the providers."

We all have a role and responsibility to improve quality and patient safety, but we must play as a team.  Instead of an individual person working in isolation or management working without frontline input, we must work together to build quality and safety.  To do this, we have to know and trust each other, which is best enhanced when we communicate face to face.  Only by talking to each other do we start to understand different perspectives on work, and only then do we truly begin to improve the systems we work in. 

Checklist: What can you do next

• Download the  What matters to you – Conversation Guide for Leaders, adapted from the Institute for Healthcare Improvement (IHI) original framework, to support leaders within the veterinary sector in introducing the Joy in Work concept to their team, engaging and empowering them in continuous Quality Improvement. 
• Join the 'What matters to you' conversation with RCVS Knowledge, in the series of Vet Times articles about improving joy in work. By asking this simple question, we gain valuable insight into what lies beneath our combined commitment to give the best possible care and can be the first step to improving workplace well-being. 
• While protocols are rigid statements allowing little or no flexibility in the process being described, guidelines are based on best available evidence to help clinicians make decisions, taking into account individual cases. Have a look at the guidelines page, with tools and resources to help you develop your own guidelines. 
• Access the free Quality Improvement Boxset, a series of small bite-sized resources where you can learn about Quality Improvement, including how to conduct meetings in practice, and carry out audits to assess your systems of work. 
• Have a listen to this podcast from the QI Boxset series, where Pam Mosedale, QI Clinical Lead, chats with Professor John Williams, National Surgical Lead at Vets Now, about systems of work and meetings to aid communication in practice. 
• Read this previous QI Feature 'Adopting change: Why it took 30 years to start washing our hands' to discover how working with a shared purpose, supporting and engaging our team can bring about improvements
   

References

1.    Introducing CHFG eLearning [Clinical Human Factors Group] [online]. Available from: https://chfg.org/ [Accessed 12 July 2022]

2.     Shorrock, S. (2016) The varieties of human work [Humanistic Systems] [online]. Available from: https://humanisticsystems.com/2016/12/05/the-varieties-of-human-work/ [Accessed 12 July 2022]

3.    Quality, service improvement and redesign (QSIR) tools [NHS England] [online]. Available from: https://www.england.nhs.uk/sustainableimprovement/qsir-programme/qsir-tools/ [Accessed 12 July 2022]

About the author 

Angela Rayner BVM&S MScPSHCF MRCVS

Angela is a Quality Improvement Advisor for RCVS Knowledge, Director of Quality Improvement for CVS, and is an RCVS Knowledge Champion for her role in improving CVS’ systems for controlled drugs auditing.

In 2021, Angela completed a MSc in Patient Safety and Clinical Human Factors at the University of Edinburgh. The programme supports healthcare professionals in using evidence-based tools and techniques to improve the reliability and safety of healthcare systems.

It includes how good teamwork influences patient outcomes, key concepts around learning from adverse events and teaching safety, understanding the speciality of clinical human factors, as well as the concept of implementing, observing and measuring change, monitoring for safety, and it focusses on quality improvement research and methodologies.