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This studied self-reported workarounds in healthcare (4k nurses & 63 US hospitals) and matched it to pressure injury incidence data (>21k patients).

Workarounds are explored in the context of the frequency of Operational Failures (OF), defined as “breakdowns in the supply of materials, equipment, and internal services needed to complete tasks”.

Thus, in this study workarounds aren’t necessarily seen as negative but could equally be positive if high levels of OF and workflow blocks are present, where workarounds may actually improve patient outcomes when nurses find local solutions to system issues.

Four categories of workarounds were used:

1. Apathetic-problem solving: Where OF occur frequently but workarounds are rarely used
2. Fire-fighting: OF and workarounds are both high
3. Process-focused: Both OF and workarounds are infrequent (e.g. higher reliability)
4. Process-avoiding: Infrequent OF but common workarounds (workarounds without a clear system need/pressure)

Results

Overall, workarounds on their own were not associated with higher rates of hospital-acquired pressure injuries.

However, a significant relationship was found when factoring OF as a mediator. That is, when nursing units have lower OF, workarounds are more associated with higher rates of injuries (higher process-avoidance is linked to worse patient outcomes).

Conversely, but not statistically significant, when OF is high, workarounds were more associated with better patient outcomes; potentially hinting that while some workarounds are harmful, others are used to improve outcomes when system problems exist.

Importantly, we shouldn’t just try to eliminate workarounds in isolation since apathetic-problem solving (high OF but low workarounds) was linked with worst outcomes. Process focused (low OF and low workarounds) had the best outcomes, whereas process-avoiding and fire-fighting were in the middle.

Overall, the authors say (p16):

• Workarounds are bad for injuries if OF are low but workarounds high
• Effects of workarounds is neutral or potentially positive if OF are high and workarounds are present, but potentially negative for some other units.

Authors state that simply reducing workarounds without addressing OF might harm patients. Also, although reducing OF may reduce pressure to engage in workarounds, it doesn’t guarantee a reduction in workarounds or improvement in outcomes – seen by the process-avoiding units who maintained workarounds even without high OF.

For me, this study supports the idea of understanding normal work and that of WAI / WAD.

Authors: Tucker, A. L., Zheng, S., Gardner, J. W., & Bohn, R. E. (2020). Journal of Operations Management, 66(1-2), 67-90.

Study link: https://doi.org/10.1002/joom.1015

Link to the LinkedIn article: https://www.linkedin.com/pulse/when-do-workarounds-help-hurt-patient-outcomes-role-ben-hutchinson