In general, making improvements in a health care system can be difficult because of time constraints, cost concerns, competing priorities, and even skepticism about whether improvement projects make a difference. Yet, a surprising barrier can be the competency, ingenuity, and individual efforts of those that work within the existing system. How can this possibly be the case?!
In an interesting article Amy Edmondson and Mark Smith (reference below) studied the organizational dynamics that sometimes hinder hospital’s ability to understand and respond to problems within their systems. This, despite the recognized importance of recognizing problems and vulnerabilities with the health system so that they can be fixed before they cause harm. The article explores the reasons why hospitals often struggle to learn from their mistakes and failures, even when they have access to valuable information that could lead to improvements in patient care and safety.
The authors carried out over 200 hours of observations of 26 nurses at 9 different hospitals, focusing on the problems the nurses encountered in their daily work. Problems were defined as disruptions in the worker’s ability to carry out a prescribed task, either because something they needed was unavailable or because something else was interfering with the work. Examples of problems include missing supplies, missing medications, or missing information, such as medical records or laboratory results. Regardless of the problem, clinical staff are facile at looking at the problems and finding ways to work around the system inefficiencies and difficulties. In some ways they feel that “the system” would collapse if they were unable to solve the many immediate problems in front of them. Working around these problems is not just part of the job, it is necessary.
The authors call what the staff are doing as “first-order” problem solving which entails being adaptable and working through the obstacles that present themselves. In some ways this is worthy of praise….and yet. These actions can mean that nothing in that system improves because individual problem solvers just take care of it.
What the authors are suggesting is that many of the problems may be entrenched, they are not so difficult that they could not be permanently fixed if people would stop fixing them and point them out as unacceptable. The very work ethic and passion to do good work, can get in the way of fixing system flaws. The problem is that over time the abilities of staff are being consumed by the organizational inefficiencies instead of being focused purely on patient care.
I love this article because it clarifies why it can be so hard to improve systems. Not only are there the concerns about speaking up, or perhaps being labeled as a complainer, or being considered not a team player, etc. It also shows that sometimes just doing a great job, overcoming problems and obstacles can also allow inefficient and vulnerabilities to remain in the system. We just take them in stride and move on.
The reference for the article is below and I was reminded of this article by the wonderful summary that is presented in the chapter Clinical interventions and process improvement in the book Patient Safety (2ndEdition by Charles Vincent). A nice reminder to speak up about those little things that are making your life harder.
Edmonson and Smith: Why Hospitals don’t learn from failures. Organizational and psychological dynamics that inhibit change. In the California management review 45(2), 55-72: 2003