1. Centre for Applied Resilience in Healthcare Organisational resilience and patient safety Dr. Janet Anderson Centre for Applied Resilience in Healthcare http://resiliencecentre.org.uk

2. Centre for Applied Resilience in Healthcare Aims – Challenge prevailing ideas about how to improve safety – Introduce the principles of resilience engineering and safety II – Show how organisational resilience can contribute to improving the quality and safety of care

3. A TALE FROM THE TRENCHES – A JUNIOR NURSE ON THE NIGHTSHIFT With thanks to Matt Alders

4. Centre for Applied Resilience in Healthcare Lessons from the trenches Constant adaptation is at the heart of clinical work Adaptation involves making decisions about – Priorities – balancing this patient’s needs with other patients’ needs, the needs of the NHS – Where the greatest risks lie and therefore where resources should be focused – How to avoid harm There is no procedure for making these decisions

5. Centre for Applied Resilience in Healthcare Traditional view - Safety I Safety is defined as a low rate of adverse events – we study safety by focusing on times when safety isn’t present Reactive – aims to prevent future incidents Focus on counting and categorising errors – error taxonomies, estimation of error rates, search for data, studies on human limits Humans as unreliable – focus on human error – control activities with procedures and protocols

6. Centre for Applied Resilience in Healthcare Traditional View - Safety I – Traditional view of safety – Processes are linear – Failure of a component or a human leads to harm

7. Centre for Applied Resilience in Healthcare Problems with Safety I Doesn’t reflect how work is done - adaptations and workarounds are ubiquitous Healthcare work cannot be fully specified If we rely on error rates to indicate safety we can only know how safe we were in the past – We need to strengthen safety in the present and future

8. Problems with Safety I Dissatisfaction with existing models and methods for improving safety – reactive, slow progress Limitations of root cause analysis, incident reporting To make progress should we do more of the same or change our approach?

9. Centre for Applied Resilience in Healthcare Safety II – Resilient Systems Resilience is the ability to adapt safely to pressures – “the intrinsic ability of an … organisation to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions” (Hollnagel, 2011, p. xxxvi) Proactive systems approach aimed at anticipating and preventing problems

10. Resilience engineering Key concepts – Work as imagined is different to work as done – Human ability to adapt and work flexibly is what creates safety – Safety and harm emerge from the complexity – We need to learn from what goes right as well as wrong

11. Success Failure Eg harm, breaches of targets, standards, staff burnout, complaints, poor experience Demand Eg attendance, acuity, standards, targets Capacity Eg staff level, skills, equipment, procedures, escalation policy Adaptations Adjustments Alignment Work as Imagined Work as Done Resilience Model

12. Centre for Applied Resilience in Healthcare Escalation in the ED Four hour target for admission to discharge for 95% Target breaches have financial consequences Escalation policy – Mix of actions designed to improve flow – Internal and external escalation actions – Pre determined triggers for action – patient numbers at various points in the patient journey Metrics – Occupancy, ambulance arrivals, acuity, average waiting times, wait for specialist, hospital bed status

13. Escalation in action Implementation of escalation – Variable practices that are poorly understood but which are crucial to success and failure Opportunities for improvement – Making the escalation process more transparent – understanding repertoire of actions and under what circumstances they are successful – Improved monitoring of escalation actions – better targeting of actions – Improved learning from what goes right Success Failure e.g. harm, breaches of targets, complaints Demand e.g. patient numbers, targets Capacity e.g. staff level, staff skills, processes Adaptations Adjustments Alignment Work as Imagined Work as Done

14. Centre for Applied Resilience in Healthcare Conclusions Organisational resilience (Safety II) is a new safety paradigm that has the potential to – Deepen understanding of every day clinical work – Strengthen safety through increasing adaptive capacity – Improve intervention design based on a deep understanding of how outcomes arise from the interplay of pressures and adaptations Focuses on flexibility within safe limits rather than controlling processes

15. Centre for Applied Resilience in Healthcare Further reading Anderson JE, Ross A, Jaye P. Resilience engineering in healthcare: Moving from epistemology to theory and practice. In Proceedings of the fifth resilience engineering symposium. Soesterberg, Netherlands: Resilience Engineering Association. 2013 http://www.resilience-engineering-association.org/download/resources/symposium/symposium- 2013/Anderson%20et%20al.%20(REA%202013).%20Resilience%20engineering%20in%20healthcare.%20Moving%20from %20epistemology%20to%20theory%20and%20practice.pdfhttp://www.resilience-engineering-association.org/download/resources/symposium/symposium- 2013/Anderson%20et%20al.%20(REA%202013).%20Resilience%20engineering%20in%20healthcare.%20Moving%20from %20epistemology%20to%20theory%20and%20practice.pdf Anderson, JE. & Kodate, N. (2015). Learning from patient safety incidents in incident review meetings: Organisational factors and indicators of analytic process effectiveness. Safety Science, 80, 105-114. doi:10.1016/j.ssci.2015.07.012 Braithwaite J, Wears R, Hollnagel E. Resilient health care: Turning patient safety on its head. Int J Qual Health C. 2015; doi: 10.1093/intqhc/mzv063. Hollnagel, E. A tale of two safeties. http://www.erikhollnagel.com/A_tale_of_two_safeties.pdfhttp://www.erikhollnagel.com/A_tale_of_two_safeties.pdf Hollnagel, E. (2013). Preface: On the need for resilience in health care. In Hollnagel, E., Braithwaite, J. and Wears, R. L. (Eds.). Resilient health care. (pp xix-xxvi). Farnham UK: Ashgate. Hollnagel E. Safety-I and Safety-II: The past and future of safety management. Farnham, UK: Ashgate; 2014. Ross, A., Anderson, J.E., Kodate, N., Thompson, K., Cox, A. and Malik, R. (2014). Inpatient diabetes care: Complexity, resilience and quality of care. Cognition, Technology and Work, 16, 91-102. doi:10.1007/s10111-012-0247-2 Ross, A.J., & Anderson, J.E. (2015) Mobilizing resilience by monitoring the right things for the right people at the right time. In Wears, R.L., Hollnagel, E. & Braithwaite, J. (Eds.) The Resilience of Everyday Clinical Work. Farnham, UK: Ashgate. Hollnagel E, Braithwaite J, Wears RL. editors. Resilient health care. Farnham, UK: Ashgate; 2013. Hollnagel E, Woods DD. Epilogue: Resilience engineering precepts. Resilience Engineering-Concepts and Precepts, Ashgate, Aldershot 2006;:347–58. Wears RL, Hollnagel E, Braithwaite J. editors. Resilient Health Care Volume 2: The Resilience of Everyday Clinical Work. Farnham, UK: Ashgate Publishing; 2015.

16. Dr Janet Anderson Janet.anderson@kcl.ac.uk Centre for Applied Resilience in Healthcare (CARe) http://resiliencecentre.org.uk/ Twitter: @CARe_KCL