Page - 136 - in Applied Interdisciplinary Theory in Health Informatics - Knowledge Base for Practitioners

engineering principles to healthcare can be traced to a meeting in 2012 of resilience engineering and healthcare safety experts led by Hollnagel, Jeffrey Braithwaite and Robert Wears and has since grown to involve a large and increasingly influential group, the Resilience Health Care Network (https://resilienthealthcare.net).[13] In the field of RHC, resilience is defined as the ability of the health care system (a clinic, a ward, a hospital, a country) to adjust its functioning prior to, during, or following events (changes, disturbances, and opportunities), and thereby sustain required operations under both expected and unexpected conditions.[14] RHC is identified with two complementary approaches to safety – Safety-I and Safety-II. Neither approach is superior, however one approach might work better than the other depending on the complexity and predictability of the situation. Safety-I is an approach that is effective for minimising error in linear systems, where the interaction between components is well characterised, resulting in well-defined and predictable outcomes. Linear systems can range from simple to complicated, but the system outcome can always be predicted with a high degree of certainty provided we know the system inputs. In linear systems, the boundaries are usually fixed or able to be clearly defined, which means that local problems can be addressed independently of the larger system, and solutions can be generalised. The best examples of linear systems are systems with primarily technological components, such as the computerised aspects of a digital heath system, or an anaesthetic machine. For an anaesthetic machine we understand how each of the electronic and mechanical parts are connected and operate so that the machine can function, and we can often predict accurately the mean time between failure for these sub-components. For a linear system, process-oriented controls such as standardisation of manufacture and operation provide effective safety measures, and barriers to error propagation across such a system can be applied effectively. Once we add a sociological component, such as normal human behaviour, into the system, it becomes more complex, and Safety-I solutions become less effective. In contrast, Safety-II is an approach that is suited to a complex system. Rather than focusing on failures, Safety-II thinking tries to understand how human performance nearly always goes well and leverages that information to improve the number of things that go right. In a complex system, boundaries can be porous, and there is significant interaction between local context and the larger system. Rather than adding system controls or barriers, which is difficult to do when boundaries are not well- defined, a Safety-II approach will try to simplify the system and rely on the adaptability of the humans in the system to adjust their performance in response to changing system demands. To apply RHC principles in the workplace to improve the number of things that go right, we need to understand ‘Work-as-Done’, or how clinicians make continuous small and large adjustments during their daily work, to satisfy the changing needs of patient care. In complex systems, ‘Work-as-Done’ is usually different to Work-as-Imagined’ by those who administer healthcare and who develop the rules and procedures that clinicians must follow. This can result in different assumptions across hospitals of how tasks are accomplished, and can make implementation of new processes and procedures difficult and, sometimes, unsafe for patients. A digital health system that is designed without in-depth knowledge of how everyday work is accomplished may not be usable by clinicians, and result in clinician frustration and workarounds. In terms of implementation science, RHC can be considered a determinant framework[15] that helps us to design and implement successful interventions through R.Clay-WilliamsandJ.Braithwaite /ResilientHealthCare136