Workaround: Trash or Treasure?

What is a workaround?

Paulo Savaget, (author of The Four Workarounds) describes the workaround as a “creative flexible imperfection loving, problem-based approach”.?It can defy and challenge convention on how and by whom a problem is solved. It can be especially suitable when traditional problem-solving methods have failed, or you just don’t have the resources or power to pursue the conventional approach.

Workarounds & Health Care

Workarounds are not new in healthcare; they often occur not because of an act of defiance but as a means to ensure timely patient care within a flawed system.?To illustrate this, we can use an example of the electronic health records (EHR).

Workarounds can exist because we have not adequately addressed new safety problems that may exist following the implementation of EHR. ?These can include different medication errors, communication problems, poor system usability and increase in clinician workload leading to dissatisfaction and burnout.?In order to cope with increasing demands clinicians, find shortcuts or workarounds to improve performance and deliver timely care.

Some of the common workarounds involving EHR are categorised using Koppel et al (2008) broad workaround categories including omission of process steps, steps preformed out of sequence and unauthorised steps. ?Other methods included bypassing patient identification and use of paper.?Probable causes of workarounds can be themed into:

·????????poor usability

·????????ease of task to complete

·????????environmental factors and constraints

·????????organisational issues

·????????technology malfunctions or problems.

Workaround can also be seen in a positive light, they can help to innovate and problem solve; they can make things work, speed up processes and improve care. ?During the pandemic, workarounds were often a daily occurrence in view that we needed to adopt technologies at speed. This highlights the importance of including health care clinicians in technology design, procurement, and implementation.?Traditionally there has been an organisational culture that excludes clinicians, typically nurses from technological decision-making and the integration of technology into practice. This has led to downstream effects such as interruptions to workflows and the necessity for workarounds.

What type of workarounds exist?

Paulo Savaget has identified 4 types of workarounds which includes:

·????????The piggyback system: capitalises on pre-existing or unrelating systems or relationships.?We see this naturally occurring in nature when we see organisms work together to the benefit of each other or themselves.?An example of a piggyback workaround includes a British couple who piggybacked on Coca Cola distribution, enabling essential medications for diarrhoea to reach outreach areas in Zambia, by inserting this medication into the crates delivering Coca Cola. This workaround ensured that essential medication reached remote areas that had been previously impossible to reach.

·????????The loophole: uses the selective acceptance or reinterpretation of the rules that define a situation. ?An example is how Women of Waves used a loophole in countries which do not legalise abortion by offering care on ships. ?By navigating and circumventing the current laws of the country they were able to operate within the law. This has also become increasingly relevant with the historic event in the US when the supreme court overturned Roe vs Wade in 2022 which means that millions of women in the US will lose the constitutional right to abortion.

·????????The roundabout: disrupts or disturbs self-reinforcing behaviour patterns. This approach has been used in India to stop the behaviour of public urination from men on walls of buildings. By placing pictures of religious gods on the walls, it appears to have given these men stage fright and has dramatically reduced this practice. This workaround has tapped into the belief systems in order to change their behaviour, but it hasn’t stopped the practice of public urination on walls which do not have pictures of religious gods.

·????????The Next Best: repurposes or recombines readily available resources in order to find different ways to get things done. We saw this during the pandemic when we saw engineering companies building ventilators and manufacturing firms producing hand sanitisers and face shields.

The Workaround Attitude and Mindset

With a curious mindset the workaround allows us to experiment in changing the settings to examine what the unintended consequences are and adjust accordingly. Outsiders to the problem can often see something new or differently because they are not accustomed to the conventional way and unlike experts don’t fixate on what they know but can see things from new angles and approach things differently.

Workarounds can celebrate and support deviance as opposed to conformity to promote opportunities. ?Deviance enables us to question the norms and challenge and transform them, but it is often not supported equally in organisations with some groups marginalised towards higher levels of conformity and rules. ?

Workarounds also enables us to challenge the status quo, they can be explored without exposing ourselves to the kind of risks of rule breaking which might otherwise paralyse us. However, to be successful in moving a workaround to an innovation relies on support from within power structures.

Workaround and innovation:

Understanding workarounds and their effect on processes and systems might enable organisations to maintain a competitive advantage. Workarounds may be the raw material for innovation and wider dissemination. Despite this some groups are rarely empowered to innovate and because they remain disruptive to the status quo, many stakeholders resist their implementation. ?Power may also influence a workaround being adopted as an innovation, as reported on The iCrowd survey on nursing and midwifery innovation, many needed the support of line managers in order to take their ideas forward.

During the COVID 19 pandemic we saw workarounds being adopted at scale and they were perceived as a necessity and encouraged. ?It was at this time that the first National Innovation Summit took place via video conference hosted by the University of Ohio focused on addressing multiple major challenges. An infographic providing an overview of the summit can be accessed here.

Common themes emerged during the summit and included:

• Insufficient time as a barrier to innovation
• Recognition that there was a need to define competencies in innovation to enable clear goals and demonstrate an understanding of innovation practice.
• Diversity and inclusion were noted by all groups as central elements of successful innovation programmes and that innovation thrives when multiple perspectives and experiences were able to be included.
• Resistance to change was noted as a barrier to new ideas such as “this is the way we’ve always done it”.
• Funding innovation was problematic and without dedicated funding innovation is pushed to the margins of nurse’s work.
• Incentive and reward systems must also recognise the nature and importance of innovation and encourage the dissemination of innovation outcomes.
• There was a need to expect failure and see the number of attempts as a measure of success. Clinicians should be encouraged to generate and pursue ideas without punishment of failure. ?The resistance of the research faculty to undertake innovation and to fail is a considerable barrier.
• It suggests utilising triple loop learning to expand on previous methods of failure analysis.?This means that we consider the identity of an organisation, the why and the who along with the what and the how.

We can utilise these various methodologies so that workarounds are more strategic, low risk and have unimagined gains. It can help us to solve problems with the resources we have and create the next best steps towards a solution. ?However, workarounds in healthcare are often born out of flawed systems and may have unintended consequences. When the risks are high which is often the case in healthcare, we should try to ensure that clinicians have the appropriate time and support to address the root causes, which initiate workarounds. ?Along with organisational support the workaround can transform into innovations and new ways of working.

Please do share how your organisation supports deviance and some of the workarounds you or your organisation may have developed. What were the consequences?