What’s paperwork got to do with healthcare improvement?
Many things impressed me when I made the move to healthcare from aviation. The sheer complexity of healthcare and the health service, the flexibility and commitment of staff, not to mention the extraordinary amount that is written and published and read by a highly literate professional community. So, perhaps ironically, the thing that shocked me most was a seemingly pervasive and pejorative attitude to ‘paperwork’. We’ve probably all heard it: ‘Forget the paperwork, I just want to treat the patient’.
Protocols, policies, checklists, standards, guidelines, reporting, records, forms and filing – admittedly there is enough of it to go around. And with increasing pressures from new quality standards, outcome measures and accountability systems, there is likely to be more of it coming to a ward near you soon. It will be greeted by a chorus of sighs and grumbles.
The problem is that paperwork – electronic or otherwise – is central to many improvement efforts. Tools like protocols and checklists aim to codify best practice, and data reporting can reveal and share critical improvement lessons.
The safer surgery checklist is one high profile example. Its national launch in early 2009 coincided with the publication of astonishing results on its effectiveness, and brought together national leaders and clinicians. There was a genuine sense of excitement and celebration that day – until, that is, the paperwork was unveiled.
The mood in the auditorium shifted palpably. A nerve had been touched. The checklist was to be mandatory. There were boxes to tick. Forms to sign. Records to file. It was ‘more paperwork’. Of course, a checklist intervention is much more than ‘just paperwork’ - but it can be very hard to see any joy or value in filling in forms.
Contrast this to aviation. The regulatory requirements – and the associated paperwork – are enormous. A common truism here is ‘when the weight of the paperwork equals the weight of the aircraft you are ready to fly’. An exaggeration, but only just. Pilots of a typical large commercial jet carry 18kg of documentation on the flight deck.
You read that right: 18kg. Loadsheets, flight manifests, airfield plates, checklists, incident reports, quick reference handbooks, technical logs, navigation charts. It's a long list. And yet I’ve never heard a pilot complain about it; never heard anyone say ‘forget the paperwork, just let me fly the plane’.
For pilots, doing the paperwork and flying the aeroplane are inextricable: doing the paperwork right is indistinguishable from flying the aeroplane right. The documentation supports them, helps them to perform at their best, guides planning and problem solving, records experience to help them improve. It’s valuable. It’s practical. More than that, it’s part of a pilot’s sense of what it is to be a professional. Flying without paperwork is unthinkable.
And it’s not just pilots. Engineers who stay on the ground are much the same. Each activity is carefully recorded, documented, signed off, double-checked. Huge effort goes into maintaining the paperwork, just as it goes into maintaining the aircraft.
So what’s going on here? Why this dramatic difference in attitudes between healthcare and aviation? It could easily be dismissed as trivial. But I’m beginning to suspect that attitudes to paperwork in healthcare are more important and more consequential than we might think. It seems to touch the core of some of our most pressing improvement challenges.
This is not just a question of ‘overload’ or ‘burden’, though quantity is clearly important. In fact, I don’t think the issue is about the paperwork itself at all. It’s about how documentation is designed, produced and reproduced – and who is involved in that process.
Effective documentation needs to be practical: useful, useable and relevant to the task in hand. Massive effort goes into designing aviation checklists to make sure they work ‘on the ground’. Good documentation also needs to be integrated. All the paperwork from all the different sources should fit together, avoiding duplication and integrating with the flow of work.
To achieve this, documentation needs to be produced collaboratively. Staff need to be actively involved in designing it, testing it, updating it and improving it. Protocols, procedures and the like should be constantly tended to and cared for. And they need to be embedded from the top down, and from the very start of education. There’s a reason that student pilots are taught to handle a checklist long before they are taught to handle an aircraft – and it goes way beyond learning how to put a tick in a box.
In healthcare, I worry about a self-reinforcing cycle in which documentation is designed far from the front line, so professionals view it as a cumbersome distraction. No wonder it produces disengagement and disenchantment.
We need to recognise that improving paperwork goes hand in hand with improving systems of care, and is a collective responsibility. Improvement interventions can live or die due to the quality of documentation – and the same, tragically, can still be said of some of our patients.
Carl is a Health Foundation Improvement Science Fellow at the University of Leicester.
In fact, healthcare boasts a veritable cottage industry of locally developed tools and documents. Each time a patient is transferred from one part of the healthcare system to the next, they acquire new documentation, although this probably still falls somewhere short of the 18kg typical of aviation. In a context in which trust in professionals has been replaced by trust in auditable systems, documentation has become an important symbol of unit standards. The difficulty is that healthcare is increasingly specialised and as Carl observes, well designed systems of paperwork should be integrated. At present they are not. So from the perspective of staff, safety systems add to this paperwork mountain.
The other problem is that developing documentation closer to the frontline presupposes that the requisite skills and knowledge are in place. The pathway community is one area where there is a strong culture of local development, partly to encourage ownership. For all the successes claimed, it is also the case that the pathway community is awash with horror stories of pathways that were developed but never implemented in practice because local developers had tried to incorporate everything and so they were thus impractical to use. Concerns have also been raised by the European Pathway Association about how far locally developed pathways are based on evidence of best practice. Yet my recent research in this area indicates pathway developers are given little training for these roles and many use them as stepping stones in their career. As a consequence there is little opportunity to develop expertise in this field.
Paperwork might look like a simple technology when compared to other examples to be found in healthcare. But protocols, pathways and decision-aides are more complex than they may first appear. There is actually a large body of social sciences research which has explored the use of such mundane technologies in practice and as such offers a knowledge base from which local developers might draw. In the context of recent recommendations for more integration of human factors and ergonomics in the training of health professionals, I suggest that an understanding how paperwork works in socio-technical systems ought to form part of this knowledge base.
You have spotted some of the obvious flaws in the NHS system.
But there are others.
1. The Nurse knows it is important, but she or he is too preoccupied to fill it in.
2. The nurse is lazy, and simply records that she has done what she has not. This is a huge problem, as a great deal of emphasis is put on recorded material,
3. The nurse wants to look good, and elaborates on what has been done, with similar ramifications to point number 2.
Now, I admit that I am biased. I trained at a time when paperwork was at a minimum - it took 15 minutes to fill in the details on 24 patients - but time was spent well. You trusted your colleagues and they trusted you. And just because that small amount of time was spent writing, did not mean that you knew your patients and their needs and worries less: I would argue that we were far more familiar with how our patients ticked when there was not the omnipresent cloud of paperwork to be filled in.
First of all the pilot will more than likely to suffer the same negative consequence of his inactions as his passengers, unlike the surgeon or nurse who fails to make a routine check. But mainly I think it is the cultural difference; engineering versus people care - the engineers are process based operators by instinct.
That said I still think there is a strong case to be made in support of the paperwork in the medical care environment but its a hard case to make in the face of so much duplication of paperwork for many on the frontline