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In the beginning … ? Date: August 10, 2015 Resilient Health Care: Moving from Safety-I to Safety-II Manly, Australia Jeffrey Braithwaite Professor and Director Australian Institute of Health Innovation Director Centre for Healthcare Resilience and Implementation Science Question 1: what’s your definition of resilience, please?
Transcript of Date: August 10, 2015 your definition of In the beginning ......•Professor Enrico Coiera Director,...
In the beginning … ?Date: August 10, 2015Resilient Health Care: Moving from Safety-I to Safety-IIManly, Australia
Jeffrey BraithwaiteProfessor and Director
Australian Institute of Health
Innovation
Director
Centre for Healthcare Resilience
and Implementation Science
Question 1: what’s
your definition of
resilience, please?
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Australian Institute
of Health Innovation’s mission
www.aihi.mq.edu.au
Our mission is to enhance local, institutional and
international health system decision-making
through evidence; and use systems sciences
and translational approaches to provide
innovative, evidence-based solutions to
specified health care delivery problems.
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Australian Institute of
Health Innovation
•Professor Jeffrey BraithwaiteProfessor and Foundation Director, AIHI; Director, Centre for Healthcare Resilience and Implementation Science
•Professor Enrico CoieraDirector, Centre for Health Informatics
•Professor Johanna WestbrookDirector, Centre for Health Systems and Safety Research
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Background - the Centre
The Centre for Healthcare Resilience and
Implementation Science (CHRIS) undertakes
strategic research, evaluations and
research-based projects of national and
international standing with a core interest to
investigate health sector issues of policy,
culture, systems, governance and
leadership.
www.aihi.mq.edu.au/chris
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Safety in Patient Care
“After decades of
improving the health care
system, patients still
receive care that is highly
variable, frequently
inappropriate, and too
often, unsafe.”1
Runciman WB, Hunt TD, Hannaford NA, Hibbert PD, Westbrook JI, Coiera EW, Day RO, Hindmarsh DM, McGlynn EA,
Braithwaite J: CareTrack: assessing the appropriateness of health care delivery in Australia. Medical Journal of Australia
2012, 197:549.
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How do organisations work?
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If your mental model is this …
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Then this is how you will deal with error …
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But healthcare really looks like this …
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And this …
Admin 1
Admin 10
Admin 11
Admin 12
Admin 2
Admin 3
Admin 4
Admin 5
Admin 6
Admin 7
Admin 8 Admin 9
Allied health 1
Allied health 2
Allied health 3
Allied health 4
EN 1
EN 2
EN 3
EN 4
EN 5
EN 6
Jr dr 1
Jr dr 10
Jr dr 11
Jr dr 12
Jr dr 13
Jr dr 14
Jr dr 15
Jr dr 16
Jr dr 17
Jr dr 18
Jr dr 19
Jr dr 2
Jr dr 20
Jr dr 21
Jr dr 22
Jr dr 23
Jr dr 24
Jr dr 25
Jr dr 26
Jr dr 27
Jr dr 28
Jr dr 29
Jr dr 3
Jr dr 30
Jr dr 4
Jr dr 5
Jr dr 6
Jr dr 7
Jr dr 8
Jr dr 9
Jr RN 1
Jr RN 10
Jr RN 11
Jr RN 12
Jr RN 2
Jr RN 3
Jr RN 4
Jr RN 5
Jr RN 6
Jr RN 7
Jr RN 8
Jr RN 9
Sr dr 1
Sr dr 2
Sr dr 3
Sr dr 4
Sr dr 5
Sr dr 6
Sr dr 7
Sr nurse 1
Sr nurse 10
Sr nurse 11
Sr nurse 12
Sr nurse 13
Sr nurse 14
Sr nurse 15
Sr nurse 16
Sr nurse 17
Sr nurse 18
Sr nurse 19
Sr nurse 2
Sr nurse 20
Sr nurse 21
Sr nurse 22
Sr nurse 3
Sr nurse 4
Sr nurse 5
Sr nurse 6
Sr nurse 7
Sr nurse 8
Sr nurse 9Sr RN 1
Sr RN 10
Sr RN 11
Sr RN 12
Sr RN 13 Sr RN 14
Sr RN 2
Sr RN 3
Sr RN 4
Sr RN 5
Sr RN 6
Sr RN 7
Sr RN 8
Sr RN 9
Ward asst 1
Ward asst 2
[Creswick, Westbrook and Braithwaite, 2009]
• Problem solving
networks in an ED
Nurses
Doctors
Allied health
Admin and support
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And this …
[Creswick, Westbrook and Braithwaite, 2009]
• Medication advice-
seeking networks in an
ED
Nurses
Doctors
Allied health
Admin and support
Admin 1
Admin 10
Admin 11
Admin 12
Admin 2
Admin 3
Admin 4
Admin 5
Admin 6
Admin 7
Admin 8
Admin 9
Allied health 1
Allied health 2
Allied health 3
Allied health 4
EN 1
EN 2
EN 3
EN 4
EN 5
EN 6
Jr dr 1
Jr dr 10
Jr dr 11Jr dr 12
Jr dr 13
Jr dr 14
Jr dr 15Jr dr 16
Jr dr 17
Jr dr 18
Jr dr 19
Jr dr 2
Jr dr 20
Jr dr 21Jr dr 22
Jr dr 23
Jr dr 24
Jr dr 25
Jr dr 26
Jr dr 27
Jr dr 28
Jr dr 29
Jr dr 3
Jr dr 30
Jr dr 4
Jr dr 5
Jr dr 6
Jr dr 7
Jr dr 8
Jr dr 9
Jr RN 1
Jr RN 10
Jr RN 11
Jr RN 12
Jr RN 2Jr RN 3
Jr RN 4
Jr RN 5
Jr RN 6
Jr RN 7
Jr RN 8
Jr RN 9
Sr dr 1
Sr dr 2
Sr dr 3
Sr dr 4
Sr dr 5
Sr dr 6
Sr dr 7
Sr nurse 1
Sr nurse 10
Sr nurse 11
Sr nurse 12
Sr nurse 13
Sr nurse 14
Sr nurse 15
Sr nurse 16
Sr nurse 17
Sr nurse 18
Sr nurse 19
Sr nurse 2
Sr nurse 20
Sr nurse 21
Sr nurse 22
Sr nurse 3Sr nurse 4
Sr nurse 5
Sr nurse 6
Sr nurse 7
Sr nurse 8
Sr nurse 9
Sr RN 1
Sr RN 10
Sr RN 11
Sr RN 12
Sr RN 13
Sr RN 14
Sr RN 2
Sr RN 3
Sr RN 4
Sr RN 5
Sr RN 6Sr RN 7
Sr RN 8
Sr RN 9
Ward asst 1
Ward asst 2
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And this …
[Creswick, Westbrook and Braithwaite, 2009]
• Socialising networks in
an ED
Nurses
Doctors
Allied health
Admin and support
Admin 1
Admin 10
Admin 11
Admin 12
Admin 2
Admin 3
Admin 4
Admin 5
Admin 6
Admin 7
Admin 8
Admin 9
Allied health 1
Allied health 2Allied health 3
Allied health 4
EN 1
EN 2
EN 3
EN 4
EN 5
EN 6
Jr dr 1
Jr dr 10
Jr dr 11
Jr dr 12
Jr dr 13
Jr dr 14
Jr dr 15
Jr dr 16
Jr dr 17
Jr dr 18
Jr dr 19
Jr dr 2
Jr dr 20
Jr dr 21
Jr dr 22
Jr dr 23
Jr dr 24
Jr dr 25
Jr dr 26
Jr dr 27
Jr dr 28
Jr dr 29
Jr dr 3
Jr dr 30
Jr dr 4
Jr dr 5
Jr dr 6
Jr dr 7
Jr dr 8
Jr dr 9
Jr RN 1
Jr RN 10
Jr RN 11
Jr RN 12
Jr RN 2
Jr RN 3
Jr RN 4
Jr RN 5
Jr RN 6Jr RN 7
Jr RN 8
Jr RN 9
Sr dr 1
Sr dr 2
Sr dr 3
Sr dr 4
Sr dr 5
Sr dr 6
Sr dr 7 Sr nurse 1
Sr nurse 10
Sr nurse 11
Sr nurse 12
Sr nurse 13
Sr nurse 14
Sr nurse 15
Sr nurse 16
Sr nurse 17
Sr nurse 18
Sr nurse 19
Sr nurse 2
Sr nurse 20
Sr nurse 21
Sr nurse 22
Sr nurse 3
Sr nurse 4
Sr nurse 5
Sr nurse 6
Sr nurse 7
Sr nurse 8
Sr nurse 9
Sr RN 1Sr RN 10
Sr RN 11
Sr RN 12
Sr RN 13
Sr RN 14
Sr RN 2
Sr RN 3
Sr RN 4
Sr RN 5
Sr RN 6
Sr RN 7
Sr RN 8
Sr RN 9
Ward asst 1Ward asst 2
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And … it’s very hard to
make large-scale change
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Example #1: harm per 1000 patients in 10 N.
Carolina Hospitals
Measures of adverse events using the global trigger tool
[Landrigan et al. NEJM 2010]
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Example #2: UK Safer Patients Initiative
Rates of cases of C difficileper 1000 bed days in control
and SPI2 hospitals.
SPI phase 2 study, 20 hospitals
©2011 by British Medical Journal Publishing Group
[Benning A et al. BMJ 2011]
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Example #2: UK Safer Patients Initiative
Rates of cases of MRSA per 100 000 bed days in control
and SPI2 hospitals.
SPI phase 2 study, 20 hospitals
©2011 by British Medical Journal Publishing Group
[Benning A et al. BMJ 2010]1
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Example 3: ACT Study of
Interprofessional practice
[Braithwaite et al. BMC HSR, 2012]
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Example 3: ACT Study of
Interprofessional practice
[Braithwaite et al. BMC HSR, 2012]
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Example 3: ACT Study of
Interprofessional practice
[Braithwaite et al.
BMC HSR, 2012]
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So we need new ways of thinking
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Beyond linear reductionism
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Health care as a complex adaptive system
• Agents
• Inter-relating
• Rich relationships
• Non-linearity
• Self-organising
• Hierarchical
• Path-dependent
• Emergent behaviours
• A Feedback occurs
• Fractal, nested
• Heterarchical
• Individuals may only know
local elements
[Braithwaite et al. 2014]
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Typical understanding of Safety
[Hollnagel et al. Resilient Health Care, 2013]
The ‘find and fix’ principle
Let’s tackle things that go wrong
A focus on what goes right receives little
encouragement
There is little demand from authorities and
regulators to look at what works well, and if
someone should, there is little help to be found
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A Different Perspective – Safety II
[Hollnagel et al. Resilient Health Care, 2013]
A different way of looking at safety
A different way of applying many familiar methods and techniques
Asks us to identify things that go right and analyse why they work
well
Requires proactive management of performance variability, not just
constraints and avoidance
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Safety II: When Things Go Right
[Hollnagel et al. Resilient Health Care, 2013]
What if we changed the definition of safety from ‘avoiding
something that goes wrong’ to ‘ensuring that everything
goes right’?
More precisely ‘ensuring that the number of intended and
acceptable outcomes is as high as possible’
This requires a deep understanding of everyday
activities
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The 10% or the 90%?
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What on earth were we thinking!
• We know a lot about when things go wrong
• But have made little progress
• We know little about when things go right
• And this everyday clinical behaviour,
relying on expertise and tacit knowledge,
creates safe effective care
• We call this Resilient Health Care
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So … we need to develop
more system resilience
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Resilient Health Care
A way of thinking about resilience:
“resilience is the intrinsic ability of a system to adjust
its functioning prior to, during or following changes/
disturbances/opportunities in order to sustain required
operations under expected or unexpected conditions”
Here are some ideas from RHC thinking...
[Hollnagel et al. Resilient Health Care, 2013]
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Work-as-imagined
vs.
Work-as-done
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Work-as-imagined vs. Work-as-done
Work-as-imagined: The rules
and standards outlining the way
things should work—proposed by
higher authorities and
management at the blunt end.
Work-as-done: The work carried
out by frontline employees at the
sharp end e.g., clinicians,
paramedics, nurses.
[Hollnagel, 2015]
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Example: The secret second handover
Problem: Ambulance queues in Emergency Departments (EDs). The longer
paramedics spend handing over patients, the longer their response time to
other emergencies.
W-A-I: The NHS, UK, created 30 minute targets, in which ambulance crews
have 15 minutes from arriving to hand over patients, and 15 minutes to finalise
paperwork. There should be one single handover to nurse coordinators.
W-A-D: Paramedics engaged in a “second secret handover” (SSH) in which
they spoke to the cubicle nurse who would be directly responsible for the
patient. This was against standardised protocols.
[Sujan, MA., Spurgeon, P. and Matthew, CO. 2015]
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We tend to figure out solutions
and ‘fix’ work-as-imagined
rather than work-as-done
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How does WAD cope with this?
Westbrook et al. (2010) observed forty doctors for 210 hours
and found….
• Interruptions occurred 6.6 times per hour
• 11% of all tasks were interrupted (3.3% more than once)
• Doctors multitasked for 12.8% of time
• The average time spent on any one task was 1:26 min
• Interruptions were associated with a significant increase in
time spent on tasks
• Doctors failed to return to approximately 18.5% of
interrupted tasks[Westbrook et al. (2010). Qual Saf Health Care]
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WAD—workarounds
Glove placed over a
smoke alarm, as it kept
going off due to
nebulisers in patients’
rooms
Plastic bags placed over
shoes to workaround the
problem a of gumboot
(welly) shortage
A leg strap holding an IV
to a pole, as the holding
clasp had broken
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First story, second story
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First story: linear thinking
Things have gone wrong
Find out what happened
Attribute actions to people
Uncover the root causes
Fix the systems so this doesn’t happen again
[Hollnagel, Dekker, Nemeth and Fujita. Resilient Health Care. P19, 22.]
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But healthcare really looks like this …
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Second story: complexity thinking
It’s more complex than the first story
It’s not linear at all
Multiple interacting variables
Uncover how come we did this many times
previously and things went right
Strengthen the systems so we do more things well
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Productive Insights into Safety
Insights from the ‘second story’ lie behind the ‘first story’ of
incidents and accidents
First stories are accounts of the ‘celebrated’ accidents which
categorise them as both catastrophes and blunders
Second stories tell how, ‘multiple interacting factors in complex
systems can combine to produce systemic vulnerabilities to failure
… the system usually … manages risk but sometimes fails.’
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Resilience and the Second Story
Resilience: − is a property of systems
− confers on systems the ability to remain
intact and functional despite the presence
of threats to their integrity and function
− is the opposite of brittleness and aspires to be a theory of systemic function
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Implications of these alternative
ways of thinking
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So:
Can we shift the emphasis to a more
comprehensive approach?
To make sure things will go right more
often?
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Discussion: comments,
questions, observations?
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Acknowledgements
My deep appreciation to Dr Robyn Clay-Williams
for her intellectual contributions to this
presentation and the many invaluable discussions
we have had about resilience; and to Ms Kristiana
Ludlow for her superb support and research skills.
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Contact details
Jeffrey Braithwaite, PhD
Foundation Director
Australian Institute of Health Innovation
Director
Centre for Healthcare Resilience and Implementation Science
Professor, Faculty of Medicine and Health Sciences
Macquarie University
NORTH RYDE NSW 2109
Email: [email protected]
Web: jeffrey.braithwaite.com
http://aihi.mq.edu.au
Wikipedia: http://en.wikipedia.org/wiki/Jeffrey_Braithwaite
2013
2015
2015
