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• Response to letter regarding 'working smarter, not harder'
  Christopher W. Hayes
  Published on: 13 May 2016
• Working smarter, not harder
  Rick A.M. Iedema
  Published on: 13 May 2016

• Published on: 13 May 2016

  Response to letter regarding 'working smarter, not harder'

  • Christopher W. Hayes, Doctor
  • Other Contributors:
    • Paul B. Batalden, Donald Goldmann

  We thank Dr. Iedema for highlighting that a gap exists in providers having the skillset to 'work smarter.' We agree that novel approaches to healthcare improvement are required that move beyond gadget-based solutions and that require a new set of skills of providers and provider organizations. The suggestion of video taping one's performance to review how the system (and its participants) currently operates and reflect...

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  We thank Dr. Iedema for highlighting that a gap exists in providers having the skillset to 'work smarter.' We agree that novel approaches to healthcare improvement are required that move beyond gadget-based solutions and that require a new set of skills of providers and provider organizations. The suggestion of video taping one's performance to review how the system (and its participants) currently operates and reflect on how to (re-) design their workflows is intriguing. It exemplifies the concept of 'exnovation' or 'innovation from within', meaning innovation arises from within established practice, and from within practitioners.

  However, our article did not aim to imply that it is providers who are responsible for, or required to gain the skills to work smarter. Our message is directed to all those seeking and driving healthcare system improvement. Although we agree that providers may benefit from the skillsets that Dr. Iedema proposed, we believe that those seeking change also need additional skillsets and perspectives. We can no longer presume that healthcare providers have the space to add new tasks, workflows, procedures etc. We have, as a system, to work on simplifying the current work environment, finding non-value added tasks and work with healthcare providers to design ways of achieving improved outcomes that don't add net new workload or complexity. Now some may argue that added work at one part of the system may have larger benefits downstream. This may be true but those charged with carrying the weight of the new tasks have to do so in a sustainable and reliable way. Otherwise subsequent change initiatives will disrupt this balance and its downstream benefits.

  Our message was also aimed at those adding new regulation, policies, performance measures and incentives or disincentives. Adding pressure on top of an environment that doesn't have the space nor the knowledge and skill to create it only adds to workplace burden, resistance and non- sustained improvement. We believe that there needs to be a system-wide look at the capabilities and investments required to create a 'working smarter' healthcare system. Providers will play their role but they need a commitment that a 'work harder' strategy is no longer acceptable.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 13 May 2016

  Working smarter, not harder

  • Rick A.M. Iedema, Professor

  The Hayes, Batalden and Goldmann piece is an important contribution to the debate about what exactly is practice improvement. Most practice improvement thinking is anchored in the 'innovation' paradigm, and this paradigm is predominantly 'gadget thinking'. Others' solutions are to be adopted here because they produce great outcomes elsewhere. Except now we have to figure out how we can get the gadget to work. Few commen...

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  The Hayes, Batalden and Goldmann piece is an important contribution to the debate about what exactly is practice improvement. Most practice improvement thinking is anchored in the 'innovation' paradigm, and this paradigm is predominantly 'gadget thinking'. Others' solutions are to be adopted here because they produce great outcomes elsewhere. Except now we have to figure out how we can get the gadget to work. Few commentators have been game to shift towards acknowledging that care practices are now too complex for 'gadget thinking'. Hayes and colleagues are an exception. They propose that frontline professionals themselves need to become smarter at 'co-designing' solutions that suit their unique contexts and practices. Here, we are not talking about adopting new gadgets from elsewhere. We care talking about people who will - and who have the skill to - take inspiration from the smartness that may be invested in whatever gadget or improvement initiative, and apply this smartness to their own workpractices. Indeed, these professionals may not even need inspiration to come from elsewhere: they may well be motivated by issues arising in their own work, and decide to redesign their practices. But to date, we have not focused on what this ability to co-design care practices consists in. We expect frontline professionals to somehow know how to co-design practice, and know how to be smart about what they do and what they should do. And yet, their training has not skilled them in practice design. We nevertheless expect them to readily (re)design the organisational dimensions of their work. Usually, such designs fall prey to people's espoused ideas and pre-existing assumptions about how things work and should work. Often there are worrying gaps between what people know and what they (think they) do. Put differently, smartness, in the sense of learning about how to manage complex situations and improve complex practices, is rare. Smartness cannot be expected to exist or arise in situations where there are no resources available for professionals to learn about (or 'make explicit') the complexities of their own day-to-day work. Smartness must be nurtured. The way par excellence to achieve this is professionals, just as do top- end athletes, studying their own performances. In sport, video-ing one's game for transforming good performances into excellent ones is now not just common but also indispensable. This is about capitalising on and building on existing strengths. By analogy, video-ing in situ practice and using the resulting footage to reflect on the work is central to enhancing smartness at work. This is what Katherine Carroll and Jessica Mesman and colleagues have referred to as 'exnovation'. Of course, many excuses and objections are raised to auto-observation, the most common ones of which are privacy, the Hawthorne effect, and subpoenable evidence. But these concerns are over-stated, and they trade a real need and opportunity for improvement and smartness off against maintaining the status quo. Without auto-observation, existing habits and routines will go on unquestioned. Work can only become harder, as the only solutions to improvement will remain gadget-based. Smartness, by contrast, starts from where we are, and explores where we can go.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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