Practice / Why people don’t use it

What was in the way

People use a system when the team behind it understood what stands between them and the safe way of working. The answer is rarely on the roadmap.

A smudged label#

A nurse is about to give a patient their medicine, and the barcode won’t scan because the label is smudged.

So she copies the medicine details out of the ordering system and pastes them in. The right medicine reaches the right patient, and the check that catches the wrong medicine is gone.

In 2008, the sociologist Ross Koppel and colleagues studied nurses working around a barcode system like that one. They found 15 different workarounds and 31 causes behind them, and one of the causes was how many patients each nurse had.

The question I changed#

The question I used to ask was how to make the system better. The more useful question is how somebody ended up where they are, what they were trying to do that day and what got in the way.

The obstacle is rarely obvious, because it’s rarely one thing. Some of it is about attention, some about fear, some about the room somebody is standing in and some about their own life.

Six kinds of barrier#

Each kind of barrier needs a different fix, so reaching for the wrong one costs a release.

The job and the equipment: a label that won’t scan, a reader that fails twice, and 11 patients on one shift
Fear of what happens next: everybody saw the near miss, and they expect blame, embarrassment or 40 minutes of typing
No room: the safe way takes 11 minutes somebody doesn’t have, and being short of anything takes their attention first
No say: somebody whose judgment has been taken away for long enough pushes back or checks out, and both of those look like breaking the rules
Where it ends up: somebody has watched a report get used in a colleague’s review, and is deciding accordingly
Protecting somebody else from the system, which is the one teams rarely plan for

A workaround is a diagnosis#

The nurse’s workaround fits one of three groups the researchers found: steps skipped, steps done out of order and steps nobody was allowed to do.

Each of those 15 is somebody getting the job done with what they had, so the list reads as a set of requirements.

When the system itself is the barrier#

Sometimes somebody leaves a question blank because they know exactly what their answer would set off.

Most families investigated for neglect are poor. In the studies, around 85% of them live on less than twice the poverty line. Being poor isn’t neglect, yet the two get written down in the same place.

People who study one widely used screening tool have traced a loop. Hardship pushes a score up, then asking for help with the hardship pushes it up again. A higher score sends more people to the house, each of them required to report what they see. Their reports then read as proof that the original score was right.

A caseworker who leaves that question blank is taking on a risk the system tried to hand to a family. Nothing on the dashboard shows what she did, so on every report she looks like the one falling behind.

A team about to make that question required can first work out what people will type into it. Something will get typed, and it will look fine.

Fairness does more than monitoring#

When people skip a rule, the reflex is to watch them harder. In 2005, the researchers Tom Tyler and Steven Blader studied why employees follow rules. They compared fear of getting caught with a belief that the company is fair and shares their values.

Fairness did more. Monitoring works too, but it was the weaker of the two. Monitoring is also what fits on a dashboard, which is why it tends to get built.

Leaning on threat can also wear down somebody’s own reasons for following the rule. So monitoring added to fix a compliance number can use up the very thing that was producing the compliance.

What it changes in the work#

Most of this starts with the questions a team asks before it builds.

Ask what got in the way on the day, before asking how to make the system better
Name the kind of barrier before choosing a fix
Read every workaround as a requirement
Before making a question required, find out what an honest answer would set off
Build for fairness before adding monitoring

Back to the smudged label#

A team that asks what got in the way that day finds the smudged label and the busy shift behind it. Fixing those means the nurse never has to choose between the check and the patient.