Resilience engineering as a quality improvement method in healthcare

Abstract

Current approaches to quality improvement rely on the identification of past problems through incident reporting and audits or the use of Lean principles to eliminate waste, to identify how to improve quality. In contrast, Resilience Engineering (RE) is based on insights from complexity science, and quality results from clinicians’ ability to adapt safely to difficult situations, such as a surge in patient numbers, missing equipment or difficult unforeseen physiological problems. Progress in applying these insights to improve quality has been slow, despite the theoretical developments. In this chapter we describe a study in the Emergency Department of a large hospital in which we used RE principles to identify opportunities for quality improvement interventions. In depth observational fieldwork and interviews with clinicians were used to gather data about the key challenges faced, the misalignments between demand and capacity, adaptations that were required, and the four resilience abilities: Responding, monitoring, anticipating and learning. Data were transcribed and used to write extended resilience narratives describing the work system. The narratives were analysed thematically using a combined deductive/inductive approach. A structured process was then used to identify potential interventions to improve quality. We describe one intervention to improve monitoring of patient flow and organisational learning about patient flow interventions. The approach we describe is challenging and requires close collaboration with clinicians to ensure accurate results. We found that using RE principles to improve quality is feasible and results in a focus on strengthening processes and supporting the challenges that clinicians face in their daily work.