ISQUA16-2509QUALITY AND SAFETY IN THE OLDER PERSON'S UNIT: A RESILIENCE ENGINEERING APPROACH

Abstract

Objectives: The Older Person's Unit presents a challenging clinical environment in which multi-disciplinary teams must work together in order to achieve a range of patient objectives. We argue that a Resilience Engineering approach offers valuable insight to understanding the complexities associated with routine work in this context. Method(s): This study, set in the Older Person's Unit of a large London teaching hospital, utilises a Resilience Engineering approach in order to better understand the complexity surrounding this clinical setting. Over the course of an 18 month period, the research team were embedded within the hospital environment collecting a wide range of qualitative and quantitative data. The study generated extensive data, including over 60 hours of observational data and 15 interviews with staff across a range of clinical roles, as well as experiential reflection by the researchers. The process of data collection was informed by a theoretical model of resilience in healthcare system performance, as outlined by Anderson et al. [2016]. Result(s): The research process identified six broad themes that captured important aspects of work in the Older Person's Unit. The themes were: discharge planning and Multi-Disciplinary Team meetings (MTDs); performance review and learning; family and social services; staff roles and clinical task co-ordination; care delivery; and acute disruptions. For the purpose of this presentation, we focus specifically on discharge planning and MTDs. The research indicated that patient discharge is a complex process requiring continual adjustment and adaptation in response to evolving patient needs, and to a wide range of internal and external hospital pressures. Coordinating mechanisms include artefacts for sharing information, case presentations and discussions, and the MTD meetings. Findings further highlighted misalignments between the demand for services post-discharge and the availability of those services, as well as variability due to individual patient factors including the availability of carers, personal preferences, and home environment. Staff must also successfully manage competing priorities by trading off goals. For example, discharging a patient even if they may not be 'completely ready' (and at higher risk of readmission) might become necessary because of an infection outbreak or pressure of bed availability. Conversely, patient stay may be extended last minute because of concerns about safety at home. In summary, the study highlighted that monitoring the complex discharge process and determining what criteria remain to be fulfilled before patients can be discharged is difficult because there is no up-to-date artefact documenting patient progress that is shared across the different staff groups. Furthermore, coordinating mechanisms for discharge activities lack transparency, are heavily reliant on nursing resources and may be heavily disrupted by small disturbances. Conclusion(s): We argue that a Resilience Engineering approach provides the insight to better understand the complexity of activities associated with the Older Person's Unit. The approach therefore lends itself well to inform quality improvements and may pave the way in offering guidance for interventions which can support staff to anticipate, monitor, learn and respond to system demands in the clinical environment.