Safeguarding Quality or Papering over the cracks?
The Cumberland Initiative
Principal investigator: Davina Allen
We are rightly and increasingly concerned with healthcare quality and safety and inspired by the way other sectors have applied check lists, pro-formas, and algorithms to tame dangerous processes. We have bought the message that simple measures can safeguard patients. But does the routine, mundane even, use of such paperwork and technology in other sectors mean that it will or can make healthcare safer? The late Prof Aidan Halligan used to talk about ‘paper safe’ and ‘really safe’ and with modern healthcare systems drowning in paperwork, I have concerns that behind their laminated facades all that glitters is not the gold standard.
Three things worry me about this fixation with paperwork and leave me wondering how many of our problems it is really fixing. First, I am concerned that much of the paperwork Tsunami is driven by the demands of what Michael Power calls the Audit Society. In a context in which we have lost faith in experts, trust in professionals has been replaced by trust in auditable systems and documentation has become evidence of service quality. Second, and related to this, is the danger that we mistake the paperwork for the performance itself. We are content that risk assessment forms are completed but do not ask what steps were taken to mitigate identified risk. Finally, once the paperwork becomes the proxy for the legitimate activities of the organization, we are open to all kinds of mythology, where the paperwork is valued for what it signifies rather than for what it does. Accounts of how these seemingly simple technologies have averted catastrophic disasters in other sectors, make them an attractive way for organizations and healthcare professionals to signal to the outside world that they are making a good faith effort to address quality and safety. But confronted by multiple pressures, there is a tendency for healthcare organizations to reach for an off the shelf solution without considering how the new technologies will be incorporated into existing work practices.
My research draws on social science to examine the use of everyday technologies in healthcare, and it is clear that these simple interventions are changing delivery processes, but not necessarily in the way we want. This is not a cri de cœur against bureaucracy. Of course almost every piece of paper was designed by someone who really cared about solving a real problem. But if we want everyday technologies to make an impact in our improvement initiatives, then there is a need for their systematic and critical analysis. Which is why, in a recent editorial in BMJ quality and safety I proposed a new subfield of research: formacology.
Davina Allen is Professor of Healthcare Delivery and Organisation and Deputy Head of School (Research and Innovation) at Cardiff University. This blog is based on her recent editorial From polyformacy to formacology