Video Transcript: Solving Workarounds

Steven Spear, DBA, MS; Senior Lecturer, Massachusetts Institute of Technology; Senior Fellow, Institute for Healthcare Improvement

We start with an important question. What are workarounds? Why are they bad and how do we avoid them? So let’s start with an example.

My friend, Rick, he’s a dentist. Patient walks in — the guy’s eating only soft food, he’s chewing on his left side, and on his right side [he’s got] kind of a pinch between his cheek and gum. He’s got an aspirin to alleviate pain. And you start thinking about the situation. What’s going to happen? One, the soft food — well, he’s limited to what he’s eating, so he’s probably going to end up malnourished if he continues with this working around the problem. You can say facetiously, his jaw’s going to cramp up because he’s chewing on one side and not using his whole head to do his eating, and he’s for sure if he keeps putting an aspirin between his cheek and gum, he’s going to get some kind of ulceration.

Now what should he do? What he should do is what he finally realized he should do — he should go to my friend Rick. Rick’s going to examine him; he’s going to diagnose why he’s feeling some kind of pain, discomfort, and so forth. He’s going to figure out a treatment plan to deal with that, and whatever treatment is appropriate for that dental problem, he’s going to apply the treatment, and then he’s going to follow up to see if it worked. And if he does that, what’s the consequence? The guy’s going to end up in a much better state than the one in which he started.

So how does this carry over to the work clinicians do and that we do in general? Well, when we go into the workspace, we’re often confronted by risk; by hazard; by acts of omission, commission, inconvenience; and so on and so forth. And very often what we do is we adapt a sort of heroic persona and do just about anything to get the job done — and very often we succeed at getting the job done. But by acting in this heroic way of making do somehow and chasing down this resource, this supply, extending ourselves beyond what was expected or otherwise needed, what we do is we preserve the conditions which caused the problem in the first place. And so we make two guarantees. One, we guarantee for sure that the aggravation we had today, we’re going to have that aggravation tomorrow and the day after and the day after that. And the other thing that we guarantee is that we’ve left the risk in the system and that all the factors that caused this daily aggravation may combine in exactly the right combination, exactly the right combination to cause a catastrophe.

And I don’t want to dwell too much and take this into a very depressing direction, but when we start looking at real public catastrophes — it could be the Challenger or Columbia Space Shuttle disasters, the problems BP had in the Gulf of Mexico or Texas City, even 9/11 — one of the things that’s striking about all of these is that when commissions study the catastrophe, they generate these gigantic reports — hundreds and hundreds of pages. And the reason they’re hundreds of pages is they start to document all the things that went wrong on the day of the event, and it runs into lists that are dozens, if not hundreds, of things that went wrong on the day of the event. But the reason the reports get so big is that the commissions start documenting all the times those events went wrong every day preceding the event — and the only thing unusual about the day of the event was the combination in which these otherwise normally occurring experiences happened. And so what we want to do is get ourselves out of that — where we have the recurrence of daily aggravation and the risk that something catastrophic occurs.

So how do we that? Well, when we do our work — and we have to do our work every day — we owe it to ourselves and clinicians owe it to their patients and to their colleagues and to themselves, also, to do their work and periodically — maybe it’s mid-shift, end of shift, end of session — step back and ask the question, “What went wrong?” And again, this should be a natural act for clinicians, right, because they’re always patients what’s wrong, what’s the problem, what’s the symptom. And, so, do the same thing for their own experience doing work.

And when they step back and ask the question, “What got in my way?” then take the next natural step for a clinician and say, “Well, why did it get in my way?” Do the diagnosis of the system much like they would do the diagnosis for the patient. And if they have some reasonable sense of cause for the problem they’ve encountered, then also take that pause to say, “Well, what can I — what can we — do differently going forward that will address the causal factors and remove the bad experience?” And try those changes, and if those changes work — well, if those changes don’t work, repeat the cycle of understanding what’s gone wrong, understanding why it might have gone wrong, and trying to make a change. But when they finally get to the point after repeating these clinical cycles — but on their work, and not just on patients — repeating these clinical cycles, that they’ve actually gotten to the point of having a good solution, share that solution with others so that they can put it to effect in their work, too.

Now if we do this repeatedly — do our work, step back and figure out what went wrong, figure out why it went wrong, what we can do differently — and cycle through until we have a reasonable solution, a couple of things happen. One is that we remove at least one source of continuing aggravation. Now, we may move onto other sources of continuing aggravation, but we reduce the aggravation we’re experiencing every day. The other thing we do is we keep pulling risk out of the system that somehow the right factors combine in the right way to cause the system to fail in some catastrophic fashion. Now, if we do that long and short — if we start converting workarounds, start converting workarounds into these learning loops — what we effectively do is we start building the dynamic of continuous learning, continuous improvement, to discover our way to greatness and start removing waste and impediments and distractions from the work we do, and [we] get to much better workflows where we provide better care to more people more affordably, and do so in a way that is much less overburdened to the people providing care.