Delivering Resilient Health Care

Erik Hollnagel, Jeffrey Braithwaite, Robert L. Wears, Erik Hollnagel, Jeffrey Braithwaite, Robert L. Wears

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781138602243
• eBook ISBN: 9780429891526
• Edition: 1
• Topic: Technology & Engineering
• Subtopic: Cognitive Psychology & Cognition
• Index: Technology & Engineering

Health care is under tremendous pressure regarding efficiency, safety, and economic viability. It has responded by adopting techniques that have been useful in other industries, such as quality management, lean production, and high reliability – although with limited, and all-too-often disappointing, results. The Resilient Health Care Network (RHCN) has worked since 2011 to facilitate the interaction and collaboration among practitioners and researchers interested in applying concepts from resilience engineering to health care and patient safety. This has met with considerable success, not least because the focus from the start was on developing concrete ways to complement a Safety-I perspective with a Safety-II perspective.

Building on previous volumes, Delivering Resilient Health Care presents documented experiences and practical guidance on how to bring Resilient Health Care into practice. It provides concrete advice on how to prepare a study, how to choose the right data, how to collect it, how to analyse the data, and how to interpret the results. This fourth book in the Resilient Healthcare series contains contributions from international experts in health care, organisational studies and patient safety, as well as resilience engineering.

This book provides a practical guide for delivering resilient healthcare, particularly for clinicians on the frontline of care unsure how to incorporate resilience into their everyday work, managers coordinating care, and for policymakers hoping to steer the system in the right direction. Other groups – patients, the media, and researchers – will also find much of interest here.

Chapter 1

Coming of age

Jeffrey Braithwaite and Erik Hollnagel

In this, the fourth volume focusing on understanding health care from a resilience engineering perspective, the focus has changed from theorising about, describing and analysing resilient health care (RHC) to examining how best to study it. Before we can articulate this, however, it might be considered wise to say a few words on how we got to here.

The first book on RHC, brought together by the community of interested parties in the Resilient Health Care Network (RHCN: www.resilienthealthcare.net), offered a series of arguments and presented a number of case studies that provided the first comprehensive description of RHC (Hollnagel, Braithwaite and Wears, 2013c). After lamenting once again the difficulties that health systems face in providing care to patients and pointing out how conventional solutions were not working, the first book introduced to a health and medical audience the insight that failures and successes both ‘have their origin in performance variability on individual and systemic levels’ (Hollnagel, Braithwaite and Wears, 2013c, p. xxiv) and that failure is the flip side of success. The proper focus for those seeking to understand how care is and can be delivered should be the continued functioning of systems under challenging circumstances, rather than the search for and rooting out of errors and mistakes. This led us to document ideas about Safety-I and Safety-II and the complementary nature of these views and to note that Safety-I is reactive and defined as the relative absence of adverse events, whereas Safety-II is prospective and defined as the ability to succeed under varying conditions. A useful way of summarising the first book and the core concepts we were playing with across its pages is the Word Art (https://wordart.com/) or visual snapshot of the common constructs of the volume shown in Figure 1.1. The frequently recurring words highlight the essential content of the book: resilience, care, health, patient, safety, organisation, processes, change, success, work, systems and performance.

Figure  1.1  Common themes from ‘Resilient Health Care’.

The second volume in the series (Wears, Hollnagel and Braithwaite, 2015a) homed in on the work that takes place on the frontlines of care, where patients are kept safe and programmes of activity are carried out. The dominant theme we had coalesced around in the second of the, by now annual, RHCN meetings was that we needed to understand how care took place at the ‘clinical coalface’. It had become abundantly clear that everyday performance is characterised by how people constantly modify what they do in order to accomplish their work. This everyday clinical work (ECW) is where things happen frequently, and it is the unfurling of daily activities of frontline clinicians that explains people’s contributions to resilient health care. This is centrally about how people actually get their work done, regularly and routinely, and how they in most cases manage to keep patients safe despite all sorts of pressures and resource constraints. The Word Art in Figure 1.2 provides the key concepts from the second book. Again we see resilience, care, health, safety and patient as recurring words, but we also see aspects of the everyday on the frontlines of care, such as practice, case, adaptive, medical, physician, nurse and discharge.

Figure  1.2  Common themes from ‘The Resilience of Everyday Clinical Work’.

By the time we got to the third volume in the series (Braithwaite, Wears and Hollnagel, 2017), we were ready to look at resilient practices from two contrasting standpoints: Work-as-Done (WAD) and Work-as-Imagined (WAI). Even a cursory inspection of a health system leads to a conclusion that WAD differs from WAI. Another way of saying this is that there will always be a gap in understanding between those who plan, prescribe, fund or mandate initiatives to keep things safe and those who treat, care for or intervene directly to alleviate patients’ conditions. This is, and indeed must be, the case both logically and in practice. In any system as complex as health care, with its intricate and elaborate mix of resources, staffing categories, resource allocations, politics and professional interests, structured into hierarchies and heterarchies, there will be an inevitable separation between those with global responsibility for the enterprise and those conducting operational work. The third volume explored the nature of this distinction, which in the industrial safety literature is known as the difference between what happens at the sharp end and at the blunt end. The third volume made the case that there is a need to reconcile the two world views, regardless of differences in WAI-WAD responsibilities or roles. It is essential to recognise that the issue is not whether WAD is ‘right’ and WAI is ‘wrong’, or vice versa. The reconciliation is necessary because it is impossible that clinicians doing the work of health care could carry out all the instructions, policies procedures and rules that are specified for them just as it is impossible that policy makers and managers who rely on WAI could alter the rules, policies and procedures such that they corresponded with WAD. Figure 1.3 displays the core concepts embedded in this volume, with work, improvement, training, simulation, reporting, management, and of course WAD and WAI, being emphasised.

Figure  1.3  Common themes from ‘Reconciling Work-as-Imagined with Work-as-Done’.

Along the way to publishing this trilogy, we also released a White Paper on behalf of the RHCN such that as wide an audience as possible would have access to some of the ideas expressed in the series (Hollnagel, Wears and Braithwaite, 2015). This traced a historical argument for some of the major developments in resilience engineering (RE) from its early beginnings, and its application to health care more recently. It also contained a series of definitions for some of the constructs appearing in the RHC books, such as WAI-WAD, Safety-I and Safety-II and sharp end–blunt end distinctions. To capture the elements of this publication, we provide a fourth Word Art (Figure 1.4), with many of the terms being repeated, albeit with different emphases.

Figure  1.4  Common themes from ‘From Safety-I to Safety-II: A white paper’.

Conclusion

This chapter has illustrated the short history of the Resilient Health Care Network (RHCN) by documenting at a high level the overarching interests of the corpus of RHC activities. Clearly, the RHCN has in a few years managed to set the scene, establish a body of work, and built the credentials of the network. The RHCN has, as the RHCN website (www.resilienthealthcare.net) indicates, ‘facilitate[d] the interaction, and collaboration among people who are interested in applying Resilience Engineering to health care – practitioners and researchers alike’.

The next stage is to capitalise on this platform of activities, and examine the different ways that RHC can be studied for the benefit of these two groups – practitioners, and researchers. It is to this task that we now turn.

Chapter 2

The need of a guide to deliver Resilient Health Care

Erik Hollnagel and Jeffrey Braithwaite

Resilient Health Care (RHC), by the time of writing of this chapter, has reached the tender age of six. The developments so far have been summarised in Chapter 1 of this book, and can by now also be found in several other places, e.g., Braithwaite, Wears and Hollnagel (2015). While a comparison with the physiological and psychological development of a child is tempting (but misleading), it is more important to recognise that RHC during its first six years has become widely recognised as a viable supplement – and perhaps even a viable alternative – to the established approaches to safety in hospitals and clinics around the world. This mirrors the ways in which the same approach, Safety-II, has been welcomed by other industries. There are several differences between RHC and the established approaches, some major and others minor, that may explain why this has happened. The major of these are:

• The focus of RHC is on everyday clinical work and why it usually goes well (Safety-II) rather than on unpredictable adverse outcomes, such as incidents and accidents (Safety-I).

• RHC looks at work as it actually takes place (Work-as-Done) rather than at work as it is assumed or expected to be done (Work-as-Imagined). This applies to every kind of performance and for every level of the organisation – from the clinical ‘coalface’ to the management.

• RHC subscribes to a system-wide perspective on how safety, quality, productivity, patient satisfaction, and more, represent facets of the same reality, and on how hospitals are complex socio-technical systems rather than streamlined ‘factories’ for the treatment of illnesses and the ‘production’ of satisfied patients.

In the context of High Reliability Organisations (HRO), Weick (1987: 112) astutely noted that safety is ‘invisible in the sense that reliable outcomes are constant, which means there is nothing to pay attention to’. This partly explains the preoccupation with safety in the traditional sense (Safety-I), which actually is an obsession with the lack of safety that is marked by the unsystematic but infrequent occurrence of adverse outcomes. As Reason (2000: 4) pointed out, ‘safety is defined and measured more by its absence than by its presence.’ When something goes wrong, when the result of an activity is significantly different from what was intended and expected, usually in the sense of being worse, it is inevitably noticed or paid attention to. But when the results are as expected, then ‘nothing has happened’.

When something goes wrong there is an obvious interest in trying to understand why it happened so that we can be safe by ‘finding and fixing’ the identified causes, usually by dealing with each cause on its own. (It also helps to make us feel safe, by providing a socially acceptable explanation for what happened.) The focus of safety efforts and safety management in all industries, health care being no exception, is therefore on the occurrence of adverse outcomes and on finding means to ensure that their number is reduced, preferably to zero. Resilient Health Care itself started by addressing the concerns that had been expressed by the so-called patient safety movement (Wears and Sutcliffe, forthcoming). In that sense RHC has followed the same path as Resilience Engineering, which also started from the traditional concern for things that go wrong. Resilience Engineering did, however, from the very beginning emphasise that ‘failures are the flip side of successes’, or in other words that the outcomes we notice (as well as the outcomes that we do not notice) are produced in basically the same way regardless of whether they are acceptable or unacceptable. (This is also referred to as the principle of equivalence, cf. Hollnagel, 2012.) Work is – b...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• 1. Coming of age
• 2. The need of a guide to deliver Resilient Health Care
• 3. Procuring evidence for Resilient Health Care
• 4. Resilience Engineering for quality improvement
• 5. Using workarounds to examine characteristics of resilience in action
• 6. Simulation as a tool to study systems and enhance resilience
• 7. Exploring resilience strategies in anaesthetists’ work
• 8. Promoting resilience in the maternity services
• 9. Team Resilience
• 10. Understanding normal work to improve quality of care and patient safety in a Spine Center
• 11. Engineering resilience in an urban emergency department
• 12. Patterns of adaptive behaviour and adjustments in performance in response to authoritative safety pressure regarding the handling of KCl concentrate solutions
• 13. A case study of resilience in inpatient diabetes care
• 14. Where process improvement meets resilience
• 15. The Safety-II case
• 16. When disaster strikes
• 17. Making it happen – from research to practice
• References
• Index