• Patient safety
• Quality improvement
• Quality measurement

We thank Professor Iedema for highlighting that a gap exists in providers having the skillset to ‘work smarter.’1 We agree that novel approaches to healthcare improvement that move beyond gadget-based solutions and that require a new set of skills of providers and provider organisations are required. The suggestion of videotaping one's performance to review how the system (and its participants) currently operates and to 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 article2 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 and so on. 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 does not have the space or 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.