Case Study-When Experts Assume too Much

11 Feb

Another one of our projects written up as a case study. The project illustrated how success, coupled with routine and familiarity, can sometimes increase a teams vulnerability to sudden change….

When a team performs well, communication frequently acts as the glue which binds the performance. Members of a top performing team understand how each other make sense of situations, what words and phrases mean within a context, and pass on instructions and intent clearly. When a team member tells a colleague that the risks in a certain procedure are “significant”, they both understand what degree of risk “significant” means in relation to the procedure. There is no mismatched assumptions and second guessing. But problems occur when a regular team member leaves or is sick, and is replaced with someone new to the team. Communication can no longer be taken for granted, but it frequently does in these situations. Assuming someone new will understand the intent behind communication in the same way as someone who has been a team member for two years can be costly at best and catastrophic at worst. Inside of two days we able to provide a solution which ensured that new and temporary staff working in the NHS were able to pick up the intent of a well-established team immediately.

A multi-disciplinary team operating in the UK National Health Service (NHS) had an outstanding performance record. Despite the team being composed of different professional backgrounds, they were able to pass on diagnosis and perform patient treatment plans with consistent success. Each team member understood the intent behind decisions and instructions. Once a patient case was passed from one team member to another, there was no perceived need to check whether instructions were being carried out as intended. This freed up time for patients and care, contributing to the efficiency and overall quality of care. However, when new or temporary staff (bank staff) worked with the team they noticed that efficiency and quality dropped. Instructions were not always carried out as intended and this led to a lot of double checking. Having to check instructions were being carried out significantly reduced the team members’ time available to patients. Our challenge was to find a way of integrating new and temporary members into the team without reducing efficiency and quality.


We were able to spend an hour each with five members of the multi-disciplinary team. During this hour we used the Knowledge Capture Method (KCM) to analyse how the team currently communicated as individuals, how they prioritised tasks, made sense of complex situations, and how they dealt with incomplete and missing information. The next day we analysed the KCM data and used it to construct a map which visualised communication across the multi-disciplinary team. Using the map and analysis, we selected a simple, easy to use method of integrating new and temporary staff into the multi-disciplinary team in the minimal amount of time.


The KCM demonstrated that core members of the multi-disciplinary team used language, phrases and discrete local knowledge which was particular to them. This made it easy to communicate intent and trust familiar colleagues to carry out tasks without checking, and this was a source of its high performance levels. However, the team were unaware of the amount of assumptions present in their method of communicating. When a new or temporary member of staff joined the team it was unnecessarily difficult for them to understand the intent within communication. To solve this we used a simple script to structure the communication of intent when core members of the multi-disciplinary team were communicating with new and temporary members. The script added no extra time or tasks to the existing workload and reduced assumptions and misunderstandings immediately.



One Response to “Case Study-When Experts Assume too Much”


  1. Health Care and the Tacit Database | Echo Breaker - May 24, 2016

    […] Tacit data provides insight on how frontline workers make sense of situations. If the sense making is shared, then staff feel more confident they are on the same page when they share information (patient handovers for example). This builds trust in teams, reducing the need to frequently re-check instructions, and focus on patient care. Examples of our work in this area is here and here. […]

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