I have just been reading a chapter on clinical risk assessment in health care by a graduate of the DMan programme, Dr Karen Norman, which is published in the book Complexity and the experience of managing in public sector organizations, London: Routledge (2005). In it she makes the helpful distinction between systems used as tools at work to help with things like work-flow, or risk assessment, and thinking about an organisation as if it were a system. As director of nursing a number of different hospitals, Karen has worked extensively with medical staff to identify and ameliorate risk to patients from medical mistakes.
So in terms of risk assessment it can be helpful to have a number of steps identified, or clear pieces of advice on how to mitigate risk in a particular area of clinical care. However, these are not enough on their own. She recounts how clinical practice often improves following an incident when things have gone wrong, only to go awry again some time later when the focus is on something else. What proves important, then, is the quality of relationships between staff which sustain conversations and reflection about practice over time. It demands teams of staff paying attention to and describing how they are taking up these ways of working in their daily practice with others and what happens as a result.
Thinking about the organisation as if it were a system can sometimes get in the way of staff taking responsibility for their part in what is going on with colleagues, she argues. Systemic approaches to risk locate the responsibility for action either with the individual or with the ‘system’. This can cause both the sense of overwhelming individual responsiblity if something goes wrong, and at the same time may inhibit taking responsibility if staff were to assume that someone somewhere else in the ‘system’ is responsible. Staff can be caught between the twin poles of fear and passivity. Karen argues instead for a relational and emergent ethics where we are responsible both for acting and not acting in our co-created patterns of relating with others. We have no choice but to act and take responsbility for that action, but in doing so we can have no guarantee that the patterning of our interaction with others’ actions will bring about the outcome we expect.
No matter how hard we try to anticipate things that might go wrong we are still capable of being surprised, and no matter how much we try to learn lessons from past mistakes we still require robust and discussive relations to make ongoing sense of what these ‘lessons learned’ mean for our practice right here, right now. It’s not the tips and advice alone, then, its about what you and I make of them as we try and move forward together