1st Edition

Resilient Health Care, Volume 2 The Resilience of Everyday Clinical Work

By Robert L. Wears, Erik Hollnagel Copyright 2015

    Health systems everywhere are expected to meet increasing public and political demands for accessible, high-quality care. Policy-makers, managers, and clinicians use their best efforts to improve efficiency, safety, quality, and economic viability. One solution has been to mimic approaches that have been shown to work in other domains, such as quality management, lean production, and high reliability. In the enthusiasm for such solutions, scant attention has been paid to the fact that health care as a multifaceted system differs significantly from most traditional industries. Solutions based on linear thinking in engineered systems do not work well in complicated, multi-stakeholder non-engineered systems, of which health care is a leading example. A prerequisite for improving health care and making it more resilient is that the nature of everyday clinical work be well understood. Yet the focus of the majority of policy or management solutions, as well as that of accreditation and regulation, is work as it ought to be (also known as ’work-as-imagined’). The aim of policy-makers and managers, whether the priority is safety, quality, or efficiency, is therefore to make everyday clinical work - or work-as-done - comply with work-as-imagined. This fails to recognise that this normative conception of work is often oversimplified, incomplete, and outdated. There is therefore an urgent need to better understand everyday clinical work as it is done. Despite the common focus on deviations and failures, it is undeniable that clinical work goes right far more often than it goes wrong, and that we only can make it better if we understand how this happens. This second volume of Resilient Health Care continues the line of thinking of the first book, but takes it further through a range of chapters from leading international thinkers on resilience and health care. Where the first book provided the rationale and basic concepts of RHC, the Resilience of Everyday Clinical Work b

    Volume 2: Preface Chapter 1 A Lesson in Resilience: the 2011 Stanley Cup Riot Chapter 2 Translating Tensions into Safe Practices Through Dynamic Trade-offs: the Secret Second Handover Chapter 3 Workarounds in Nursing Practice in Acute Care: a Case of a Health Care Arms Race? Chapter 4 The Demands Imposed by a Health Care Reform on Clinical Work in Transitional Care of the Elderly: a Multi-faceted Janus Chapter 5 The Stockholm Blizzard of 2012 Chapter 6 Individual-collective Trade-offs: Implications for Resilience Chapter 7 Managing Medicines Management: Organisational Resilience in Community Pharmacies Chapter 8 Blood Transfusion with Health Information Technology in Emergency Settings from a Safety-II Perspective Chapter 9 Exposing Hidden Aspects of Resilience and Brittleness in Everyday Clinical Practice Using Network Theories Chapter 10 Patient Boarding in the Emergency Department as a Symptom of Complexity-induced Risks Chapter 11 Looking for Patterns in Everyday Clinical Work Chapter 12 Tempest in a Teapot: Standardisation and Workarounds in Everyday Clinical Work Chapter 13 ECW in Complex Adaptive Systems Chapter 14 Revealing Resilience through Critical Incident Narratives: a Way to Move from Safety-I to Safety-II Chapter 15 Patients as a Source of Resilience Chapter 16 Strategies to Get Resilience into Everyday Clinical Work Chapter 17 Mobilising Resilience by Monitoring the Right Things for the Right People at the Right Time Chapter 18 Why is Work-as-Imagined Different from Work-as Done?


    Robert L. Wears (MD; MS, computer science; PhD, industrial safety) is Professor of Emergency Medicine at the University of Florida Health Science Center - Jacksonville, and Visiting Professor in the Clinical Safety Research Group, Imperial College London. He is a practicing emergency physician and has since 1994 been studying safety in healthcare settings. His specific areas of interest include resilience in small work teams, response to the unexpected, the design of artefacts to support distributed cognition, and the impact of computerized information technology on safety and performance. He has authored over 250 papers, book chapters, and essays, the most recent title being Patient Safety: A Brief but Spirited History (in Zipperer, Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer; Gower, 2014). He is Senior Associate Editor of Annals of Emergency Medicine, and serves on the Editorial Boards of Human Factors and the Journal of Patient Safety. He is also a member of the Board of Directors of the Emergency Medicine Patient Safety Foundation. Erik Hollnagel (PhD, psychology) is Professor at the University of Southern Denmark, Chief Consultant at the Centre for Quality Improvement, Region of Southern Denmark, and Professor Emeritus at University of Linköping (Sweden). He has since 1971 worked at universities, research centres, and industries in several countries, most recently as Industrial Safety Chair at MINES ParisTech (France). He has worked with problems from many domains including nuclear power generation, off-shore, aerospace and aviation, air traffic management, software engineering, healthcare, and land-based traffic. His professional interests include industrial safety, resilience engineering, accident investigation, cognitive systems engineering and cognitive ergonomics. He has published more than 250 papers and authored or edited 20 books, some of the most recent titles being The Functional Resonance Analysis Method (Ashgate, 2012), Governance and control of financial systems (Ashgate, 2011), Resilience Engineering in practice (Ashgate, 2011), The ETTO Principle (Ashgate, 2009). Erik is also Editor-in-chief of Ashgate Studies in Resilience Engineering. Jeffrey Braithwaite, BA, DLR, MIR (Hons), MBA, PhD, FACHSM, FAIM, FFPHRCP (UK) is Professor of Health Systems Research and Foundation Director of the Australian Institute of Health Innovation at Macquarie University, Sydney, Australia. He is Visiting Professor at University of Birmingham, UK, Adjunct Professor of Resilient Health Care and Patient Safety, University of Southern Denmark, and Senior International Fellow at the Canon Institute for Global Studies in Tokyo, Japan. His work investigates and contributes to systems improvement. His expertise is in empiricising and theorising about health systems including researching the culture and structure of acute settings, leadership, management and change in health sector organisations, quality and safety in health care, accreditation and surveying processes in international context and the restructuring of health services. Professor Braithwaite has published more than 300 refereed contributions, and 500 total publications and he has presented at or chaired international and national conferences, workshops, symposia and meetings on more than 500 occasions, including over 60 keynote addresses. Professor Braithwaite is the recipient as at 2014 of career research funding of US$60 million spread over 60 grants. He referees for 30 journals and the health research bodies including in Ireland, New Zealand, Switzerland and the United Kingdom.

    ’Those heading health systems and seeking to make them safer need to spend more time upstream, thinking about how to make their organisations truly resilient. This important new book walks them up the river bank.’ Sir Liam Donaldson, Imperial College London, UK ’An original, important and timely volume that applies the emerging discipline of resilience engineering to the design and improvement of healthcare systems. What makes the book so engrossing is the way it blends captivating stories (e.g. blizzards, riots) with the insights extracted from them.’ Gary Klein, author of Sources of Power: How People Make Decisions ’Anyone who is responsible for patient safety needs to understand resilience engineering, especially how people actually get their work done, which is not how those who design and manage the work expect it is being done. Resilient Health Care, Volume 2: The Resilience of Everyday Clinical Work offers understanding for managers and safety professionals about why we haven't yet made healthcare neither acceptably safe nor productive. If reliance engineering was applied more in healthcare, fewer patients would suffer and our healthcare system would get more value from the vast sums of money spent.’ Jeffrey B. Cooper, PhD, Harvard Medical School, USA 'Here is a must-have book on resilience through the eyes of a unique team: the pioneer, the researcher, and the practitioner. The term resilience has entered general linguistic use and this broad use may also leave everything vague. This second book on healthcare resilience, written by the team of the pioneer (Erik), the researcher (Jeffrey) and the practitioner (Bob) sets the record straight. It reverses usual ways to debate resilience via only theories and concepts, starts from the real world, shows every-day resilience in healthcare, listens to professionals and draws out general lessons. Some examples are closely related to clinical care, others are more about management; all are an incr