I've often been dissappointed with the quality of flow diagrams used in healthcare improvement. BUT I totally understand: a) I'm a bit of a geek when it comes to software and b) some of the software tools are just way too complicated - or worse, people try to use WORD or PowerPoint! Here is a diagram I made online in a couple of minutes. I'll be exploring more about how this tool works and post more later. I'm not promoting this particular tool - maybe I've missed other such online tools - but this makes lots of sense, especially for collaborative improvement work.

Simply, the essence of collaboration:

 

Interruption and multitasking are fundamental sources of error, that probably have a common mechanism in the brain's function as a sequntial processor. Both require switching; sequential processing means that we truly cannot multi task as far as attention is concerned. Attention in task performance is like a spot light - it can only shine on one part of a task at a time.

Interruption is an externally and culturally aligned behavior characteristic of the cultural norms established in a clinical area. It is likely influenced by relationships; for instance are you more or less likely to interrupt a friend in the middle of a task as compared with someone you don't really know? Hierarchy probably has an effect too; would you be more or less likely to interrupt someone who you perceive is lower on the hierarchy? What about patients and family; do they know when and how to get your attention safely? Do they know when you are involved in something and should not be interrupted?

Recently a friend shared an incident in which a breast milk administration error occurred even though this NICU uses a bar-code process. Upon review of the circumstance, interruption was probably a key contributing factor. The nurse was interrupted during the process and returned to complete it, missing the code scan which would have detected the wrong milk. This had become a well entrained task, repeated correctly many times, but with attention diverted the switch back to the task resulted in error.

John Medina's latest book includes this and many other little-known facts about how the brain works based on his years of working in the field. He also has a blog and a few entries on YouTube.

 

 

Healthcare workers are generally very skilled and proficient at making things work. This is highly valued when working in systems of all kinds that don't always cooperate, especially when a life is on the line. Kudos to those so skilled in using their ingenuity to make a deficient or faulty system or process function well enough to get the task completed. But I'd like to point out a flaw that needs serious and widespread attention. Behavior such as this, works around the problem and does not truly solve it. This perniciously creates a situation of dependency; a kind of addiction to the heroics of in-the-moment problem solving. Until the problem is solved, it will resurface for another workaround by the same or other ingenious person.

This can be examined in light of a systems archetype called "shifting the burden". The pattern is familiar and I've drawn out the causal loop diagram. The symptoms of an immediate problems are resolved quickly - the workaround enables the work to proceed in an oftentimes incomplete or risky manner. Usually there is fundamental corrective action that needs to be taken; requiring investigation, observation, devising and testing changes and measurement - in other words, improvement. All this requires time, and many people who work IN healthcare processes are stretched to the limit just DOING work that often requires ingenious workarounds. And the vicious cycle continues - back around to working around the problem.

The heroic workaround will live on until the pattern is broken, and this can require a significant commitment of time and money. Some organizations are making this investment, but many remain addicted to the pernicious workaround.