Yes Rollo, I’ll bring mine as well! With far too many SOPs. Standards and Guidance available our imagination runs wild. We need to hone in on the best and implement CI. Here is another formula: QI=CI, more about that shortly!

Thanks Tom for the stimulating thought!

Rollo, I think what you say is important. Here’s a related thought: providing good healthcare requires a high level of responsiveness to emerging situations that are often unanticipated in their detail. Because of this, there may be a limitation to how far work-as-done can ever reflect work-as-imagined–in part because the work itself demands creativity, flexibility, and reactivity, which can’t be fully prespecified.

Polly, The situation you describe is the same for all safety critical processes in all safety critical industries. This should not, and in other industries does not, prevent work-as-done being the same as work-as-imagined, and that work-as-done being clearly documented, monitored and continually improved. The NHS stands out as having many ‘work arounds’ Work-as-imagined. That is how you manage Quality and Safety, without that you don’t.