Shaggar posted:

it is the ultimate irony that what you are talking about here is implementing real process controls. something you claim as been done, but has never actually ever been done in healthcare. process controls and process improvement are literrally how you close that gap from work-as-prescribed to work-as-done.

the problem with the current system is they have no real process controls beyond vague guidelines, and they have no process improvement mechanisms. in many cases they cant even do real process improvement because they lack the controls and metrics to monitor things. or atleast they lack the comprehension and desire to collect the metrics.

The constant "overdosing" is a great example of how you have loads of excellent data trapped in the EHRs about the outcome of every overdose event. They should be taking that data across the entire US and using it to establish new guidelines based on actual data that eliminate the need to warn people about fake overdoses.

theres also a larger problem with people taking components of process systems when the system doesnt work unless you take all of it. project management is a great example thats simpler to understand. i.e. management takes the 2 week cadence of agile, but then leaves out all the capacity planning components and they think they're agile.

its the same thing with quality and process controls. you have to do it all or it doesnt work.

quote:

Three hundred babies died or were left brain-damaged due to inadequate care at an NHS trust, according to reports.

The Sunday Times has reported that a five-year investigation will conclude next week that mothers were denied caesarean sections and forced to suffer traumatic births due to an alleged preoccupation with hitting “normal” birth targets.

The inquiry, which analysed the experiences of 1,500 families at Shrewsbury and Telford hospital trust between 2000 and 2019, found that at least 12 mothers died while giving birth, and some families lost more than one child in separate incidents, the newspaper reported.

Sagebrush posted:

https://twitter.com/banovsky/status/1507890882938380288

DELETE CASCADE posted:

why do checklists work for pilots but not for nurses?

quote:

Healthcare checklists do not always share design features with their aviation counterparts. For an Airbus A319 (figure 1), a single laminated gatefold (four sides of normal A4 paper) contains the 13 checklists for normal and emergency operations. Tasks range from 2 (for cabin fire checklist) to 17 (for before take-off checklist), with an average of seven per checklist. Each task is described in no more than three words
and can be checked immediately, with usually a single word of confirmation. It has no check boxes, does not require signature and is designed to be used by one person, with specific checklists performed aloud.

In contrast, the Centers for Disease Control and Prevention central line-associated blood stream infections checklist11 has 18 tasks, with no less than 4 word descriptors (and up to 22 words), and describes non-procedural tasks that need to be completed over several minutes (and hours), which cannot be ‘checked’ (eg, ‘empower staff ’). The WHO safer surgery checklist (first edition) 12 has 21 tasks (7+7+7), with wording ranging from 2 to 16 per task, and involves several people simultaneously. Some tasks are easily checked and completed, while some require discussion and some cannot be ‘checked’. One feature of checklists in healthcare, in comparison to most other industrial uses, is that they increasingly feature items intended to promote communication and teamwork (eg, introductions, discussion of patient risk factors, concerns and so on), in addition to straightforward categorical checks (eg, have hands been washed, has consent been obtained and others). If used in the right way, they can indeed assist in the change of communication patterns and specific coordination tasks (such as ‘call outs’, task location and task visibility).10 However, creating an opportunity for a more general team talk is not a traditional feature or necessarily a particular strength of checklists. In fact, authentic checklist completion will rely on good communication and teamwork in the first place, which is not always the case.

DELETE CASCADE posted:

why do checklists work for pilots but not for nurses?

quote:

Stewart, in defence of his actions during the company’s own inquiry, had doggedly raised issue after issue, some of which danced around the question of exactly what had gone wrong and why. Accused, for example, of failing to file immediately upon landing the necessary MOR – ‘mandatory occurrence report.’ Stewart argued that because he had at least initiated the go-around from decision height and had landed successfully out of the second approach, it didn’t constitute an ‘occurrence.’ Few agreed.

He argued that nowhere was it officially written that a proper go around required a pitch up in the airplane’s attitude of three degrees per second, which the airline claimed was the proper technique. (Stewart had applied back yoke that rotated November Oscar at a rate of less than one degree per second).
Well, maybe not, but it is the way to get the job done.

At one point, Stewart created a transcription of every oral call-out, checklist response and radio transmission required by company and CAA regulations during the approach and demonstrated that simply reading the script aloud, nonstop, took seven minutes. The entire approach itself had consumed only four, thus demonstrating that the letter of the law required the impossible. It was an interesting point, but nobody cared.

Sagebrush posted:

Pilots can't just stop the flight when they feel like it FYI

vuk83 posted:

But they can initiate abort/divert procedures.

Midjack posted:

to be fair it's not just commercial pilots who follow checklists.

Carthag Tuek posted:

but to be serious, there wont be any meaningful change until you start putting managers, vps, & ceos in prison

MononcQc posted:

Now, the diagram I'm posting is crucial to a lot of the things referred in the paper and many other ones, and unfortunately, people in the humanities have the jankiest most loving ridiculous diagrams (there's much worse than this one):

MononcQc posted:

quote:

in order to make interesting observations, they have to be, in part, insiders in the setting they are observing, while remaining, in part, outside the domain in order to have insights about how practice works, how practice fails and how it could work better given future change. Design observations in the field of practice, where designers watch experts doing cognitive work, relies on being prepared to be surprised in order to distinguish unexpected behaviors that reveal how expertise works and how these experts work

quote:

One of the key results is that expertise uses external artifacts to support the processes that contribute to expert performance – expertise is not all in the head, rather it is distributed over a person and the artifacts they use and over the other agents they interact with as they carry out activities, avoid failure, cope with complexity, and adapt to disruptions and change.

FalseNegative posted:

This whole thread continues to be fascinating, thank you for taking the time to write these excellent posts.

FalseNegative posted:

This whole thread continues to be fascinating, thank you for taking the time to write these excellent posts.

quote:

The map allowed them to see how the system operated below the surface, integrating all the pieces to generate a comprehensive view. They commented on the uniqueness of this comprehensive view: “We don’t allow people to see the end-to-end view... to see how things interrelate.” One explained that the experience “ruins [one’s] perspective in a good way.” Another described how it gave her a “whole different way of looking at things.” By revealing the web of roles, relations, and routines that coalesce to make the organization, the map made the organization’s actual operation intelligible.
[...]
Competent members of organizations draw on everyday knowledge [...] as they perform their roles, but this knowledge does not speak to the organization’s broader order. Despite how remarkably capable these employees were at “recognizing, knowing, and ‘doing’ the lived order,” the broader order or structure is often “resistance to analytic recovery” from the inside. Even if they would like to observe and reflect on their organization’s detailed operating process, they rarely have opportunities, such as building process maps, that provide time and access.

quote:

They expected to observe inefficiencies and waste, the targets of redesign, and they did. Tasks that could be done with one or two hand-offs were taking three or four. Data painstakingly collected for decision-making processes were not used. Local repairs to work processes in one unit were causing downstream problems in another. Workarounds, duplication of effort, and poor communication and coordination were all evident on the map.

Beyond these issues, they observed a more fundamental problem. A team member explained, “I’m getting a really clear visual of what the mess is.” Standing back from the wall, he sighed, and said, “The problem is that it was not designed in the first place.” Instead of observing a system designed, adapted, and coordinated to achieve stated goals, he pointed to three examples on the map that demonstrated the exercise of agency in various places and at various levels in the organization. These change efforts lacked broader perspective and direction as well as coordination and integration with other efforts

quote:

Some held out hope that one or two people at the top knew of these design and operation issues; however, they were often disabused of this optimism. For example, a manager walked the CEO through the map, presenting him with a view he had never seen before and illustrating for him the lack of design and the disconnect between strategy and operations. The CEO, after being walked through the map, sat down, put his head on the table, and said, “This is even more hosed up than I imagined.” The CEO revealed that not only was the operation of his organization out of his control but that his grasp on it was imaginary.

They learned that what they had previously attributed to the direction and control of centralized, bureaucratic forces was actually the aggregation of the work and decisions of people distributed throughout the organization. Everyone was working on the part of the organization that they were familiar with, assuming that another set of people were attending to the larger picture, coordinating the larger system to achieve goals and keeping the organization operating. They found out that this was not the case.

quote:

Members of the organization carry on as though these distinctions are facts, burdening the organization’s categories, practices, and boundaries with a false sense of durability and purpose.
[...]
The idea that organizations are an ongoing human product was a provocative insight for these employees. This new perspective, as one explained, “made things seem possible.” Once they could see the “what” as a dynamic social creation, they could begin asking better questions about “how.” A team member explained that the logic of organization should not be fixed and how its rules, synthetic creations, are free to deviate
[...]
Their peripheral role choices allowed team members to exploit this new understanding of the organization’s operations. They could work with new assumptions about the mutability and possibility of the organization and create structures and systems to coordinate and direct the web of roles and interactions. Their new role choices also allowed them to remain above and outside of the organization’s daily operations.

quote:

As part of the map-building process, employees were invited to identify their role on the map and to indicate how it was connected to other roles through either inputs or outputs. Team members recounted that it was difficult to observe employees “go through a real emotional struggle when they see that what they are doing is not really adding value or that what they are doing is really disconnected from what they thought they were doing.” In one case, a finance manager noticed that his role was on the wall but that it was not connected to any other role on the wall. He had been producing financial reports and sending them to several departments because he understood them to be crucial for their decision-making process; however, no one had identified his work as an input to theirs.

This realization was, in the end, devastating for him. He was on the verge of tears... at first, he became very argumentative and was trying to convince people that you go from this Post-it note down here to mine. [Other employees explained] Well no, we don’t do that. It was a two-hour conversation. And he finally sat down, and he said, so why am I doing this? It was devastating.

The eventual outcome of this “aha” was that the manager was moved to another role in the department after working four years in a position that had served almost no purpose.
After such analyses, team members could not look at particular roles and people in the same way.

quote:

Their knowledge of the limits of local, small-scale change and the futility of changing parts of the organization without addressing the system as a whole, discouraged employees from returning to their career in the organization. They did not want to contribute to the mess or reproduce the mess they had observed.
[...]
What they had learned could not be unlearned or ignored.

quote:

This perspective or comprehension affects how we speak and act. We speak about organizations as if they are objects that exist independent of us, and we act as though they constrain and guide our actions. When we objectify social systems (organizations, communities, families, gender roles), we apprehend them as “prearranged patterns” that impose themselves on us, coercing particular roles and rules. We free ourselves to talk about and inhabit them as independent of us: as existing prior to us, standing before us, outliving us, and operating without us. Given this, we are relieved of greater responsibility for them. Our responsibility is to skillfully fulfill our role within these objectified realms.
[...]
Whereas, as some sociologists “know that organizations and institutions exist only in actual people’s doings and that these are necessarily particular, local and ephemeral”, employees may be less likely to know this. When they do, it problematizes their past and future participation.
[...]
The realization that social worlds do not have an independent, stable existence but instead emerge from our collective action is “sometimes arrived at in a moment of heady delight, but often as a horrifying realization”. This realization is considered a “fatal insight” because it destroys assumptions that the current order, roles, rules, and routines are given. Within the system of roles, rules, and routines, there is far more room to maneuver than previously assumed. Rejection of objectivity puts possibility, perhaps even responsibility, squarely in the court of subjectivity.

FalseNegative posted:

This whole thread continues to be fascinating, thank you for taking the time to write these excellent posts.

quote:

Humans tend to consider that their vision of the world is correct whenever events happen in accordance with their expectations. However, two sequential events can happen as expected without their cause being captured. When this is the case, humans tend to treat the available evidence as exhaustively reflecting the world, erroneously believing that they have understood the problem at hand. These co-occurring events can seriously disrupt situation awareness when humans are using mental models that are highly discrepant to reality but
nonetheless trusted.

quote:

Flaws in mental models are detected when the interaction with the world reveals unexpected events. However, these inaccurate mental models do not always lead to accidents. Very often, they are recovered from. In this respect, error detection and compensation are significant features in human information processing. The weakness of mental models lies in their poor requirements in terms of validity: If the environmental stream of data is consistent with the operator’s expectations, that is enough for the operator to continue regarding the mental model as valid. The understanding of the mechanisms generating the data is not a necessary condition.

We are not concerned here with how operators could build exhaustive mental models, as their incompleteness reflects a strong need for information selection. The issue of interest is to understand the conditions in which operators believe they have a good picture of the situation whereas the underlying causal mechanisms have not been captured.

quote:

Provided they can keep the system within safe boundaries, operators in critical situations sometimes opt to lose some situation awareness rather than spend time gathering data at the cost of a total loss of control.
Critical situations can be caused by the combination of an emergency followed by some loss of control. When this happens, there is little room for recovery.
[...]
The emergency nature of the situation and the emerging workload delayed the revision of the mental model which ultimately was not resumed.

quote:

One way of resolving this is to take a descriptive approach, such as focusing on whether people follow rules; however, this will only help in attributing blame, or judicial responsibilities, and will not help in explaining actual behaviour (i.e. why people choose to follow a rule or not).

quote:

Irrespective of the nature of the adaptive agent, the challenges described in Table 8 are not possible to resolve unless (1) it is possible to establish communication of intention between vessels or (2) it is possible to ensure that all agents follow the [navigational laws] at all times. The last request is highly unlikely to ever happen as long as pleasure craft skippers lack elementary navigational competencies and knowledge of [navigational laws].

Carthag Tuek posted:

this would not happen if Ole III had a large cannon

quote:

During missions, teams of flight controllers monitor spacecraft systems and activities 24 hours a day, 7 days a week. The head flight controller is the flight director, referred to as “Flight.” Flight is ultimately responsible for all decisions related to shuttle operations and so must make decisions that trade off mission goals and safety risks for the various subsystems of the shuttle. Directly supporting the flight director is a team of approximately sixteen flight controllers who are co-located in a single location called the “front room”. These flight controllers have the primary responsibility for monitoring the health and safety of shuttle functions and subsystems. [...] These controllers must have a deep knowledge of their own systems as well as know how their systems are interconnected to other subsystems (e.g., their heater is powered by a particular electrical bus) in order to recognize and respond to anomalies despite noisy data and needing to coordinate with other controllers.

Each of the flight controllers located in the front room has a support staff that is located in “back rooms.” The front room and back room controllers communicate with each other through the voice loop system by activating a voice loop channel through a touch screen and talking into a headset. The back room support staff are more specialized than the front room controllers on specific shuttle subsystems and monitor more detailed information sources.

quote:

By formal communication protocols in mission control, flight controllers have privileges to speak on only a subset of the loops they can listen in on. In the voice loop control interface, each channel can be set either to monitor or talk modes. Only one channel at a time can be set to the talk mode, although many channels can be monitored at the same time. In order to talk on a loop set to the talk mode, a controller presses a button on a hand unit or holds down a foot pedal and talks into a headset.

Each controller customizes the set of loops they monitor by manipulating the visual representation of the loops at their console. The controllers can save a configuration of multiple voice loops on ‘pages’ under their identification code. The most commonly used loops are grouped together onto a primary page. The controllers then reorganize and prioritize the loops to fit the particular operational situation going on at that time by changing the configuration of loops that are being monitored and by adjusting the relative volume levels on each loop.

The voice loop interface is generally considered to be easy to use and an appropriate communication tool for a dynamic environment like space shuttle mission control. The fundamental display units are visual representations of each auditory loop, which captures the way controllers think about the system. In addition, if individual loops are analogous to windows in a visual interface, then the pages of sets of loops are analogous to the ‘room’ concept in window management (Henderson and Card, 1986). Controllers are able to customize the interface by putting their most commonly used loops together on a single ‘page.’ Active loops on these pages can be dynamically reconfigured in response to the constantly changing environment. Dynamic allocations of which loops to listen to are done by directly selecting loops to turn off and on. Controllers increase or decrease the salience of particular loops by using loop volume controls to adjust relative loudness

quote:

When controllers hear about the failure on the Flight Director's loop, they can anticipate related questions from the flight director and prepare to answer them without delay. Controllers can also anticipate actions that will be required of them. For example, an anomaly in one subsystem might require diagnostic tests in another system. When the controller hears about the anomaly on the voice loops, he can anticipate the requirement of these tests, and prepare to conduct them when they are requested.
[...]
For example, if an event like a complex anomaly occurs in a shuttle subsystem, the event triggers diagnostic activity in all related subsystem teams. This activity generates more communication across teams over the voice loops. Therefore, it is possible for controllers to track the cascade of disturbances in shuttle systems by tracking the escalation of activities that occur in response to these disturbances. This general indication of activity tempo allows controllers to synchronize their processes and activities with rest of the flight control team.
[...]
In contrast to a system of direct communications where only invited parties are involved in a conversation, voice loops allow controllers to listen to communications without announcing their virtual presence. This ability allows controllers to better gauge the relevance of their communications in relation to what is happening on a loop before interrupting. Controllers are then better able to time their communications, either by speeding up or postponing communications in relation to spurts of activity or by waiting for a pause in the communications to interject.