Ensuring that as many things as possible go right in a pressure system

January has arrived, the weather has turned seasonally cold and the TV and news papers are full of headlines about the pressure evident across the health and social care system. Black alerts, no beds, patients on trolleys , ambulance teams waiting with patients in corridors, canceled operations, long waits for GP appointments and referrals, people fit for discharge and transfer unable to leave because there is no social or community support, care homes unable to recruit staff to care for residents.

Alongside those headlines are many real life stories of health and care staff frustrated by not being able to do all that they could but still doing their best, delivering all care possible, maintaining a caring attitude despite being overwhelmed. Patients, carers, colleagues still doing the right thing and delivering great care despite the pressure; so what is going on?

Working under pressure is not unusual, what ever our job we all do it; meeting deadlines, making choices between the urgent and the important, trying to do the same or do more with fewer hands. The more often we work under pressure the more “normal” it becomes, and we adjust to a new normal because people and teams adjust what they do to match the new conditions.

Personal resilience may be limited, but it is strengthened and replenished by working within a team, working with colleagues who support each other and who treat each other with trust and respect. Team work like this, is one of the greatest strengths of the NHS.

We all know what can happen when people and processes are stretched for too long, mistakes can be made, processes become fragmented, re-work more likely. The headlines tend to focus on the accidents and incidents and safety is defined as a state where as few things as possible go wrong.

But in reality as things become more complicated people adjust, especially when they are familiar with complexity, they make adjustments in order to make sure that despite the increasing complexity, things still go right. These adjustments become increasingly important to maintain acceptable performance.

Despite the obvious importance of things going right, traditional safety management has paid little attention to this.  The new challenge for safety improvement is to understand these adjustments—in other words, to understand how performance usually goes right in spite of the uncertainties, ambiguities, and conflicts that are integral to complex work situations.

As you continue to work in the pressured system, try to move from ensuring that ‘as few things as possible go wrong’  [Safety 1] to ensuring that ‘as many things as possible go right’ [Safety II] . That’s the reality which the stories, not the headlines, describe.

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