Seite - 135 - in Applied Interdisciplinary Theory in Health Informatics - Knowledge Base for Practitioners

1. The scope of Resilient Health Care When designing and implementing new digital health systems, the safety of those systems for clinicians and the patients in their care must be a core consideration. Resilient Health Care (RHC) is a relatively new approach to safety, albeit with long antecedents to resilience engineering, that shifts from understanding safety as the absence of accidents or incidents, to thinking of safety as a system where as many things as possible go well. Measuring what goes wrong has been an attractive concept for organisations in the past: there are typically few things to count, and resources can usually be brought to bear to tackle problems that have been shown to result in significant harm. Traditional approaches to safety are reactive rather than proactive; examples include regulation,[1] protocols and checklists,[2-5] Root Cause Analyses[6] and judicial inquiries to investigate patient deaths.[7] Errors after they occur are identified and rectified, and processes are put in place in an attempt to prevent future occurrences. This approach is not effective, however, where the route to error is different on each occasion, and where fixes for previous errors can contribute to new paths to failure. In contrast, RHC asks us to understand how the systems requiring action actually work, to identify what goes right and comprehend why things routinely go well, and to proactively manage variability in the workplace. This newer way of thinking is necessary for the whole gamut of systems behaviour. It is especially apposite for improving safety in complex adaptive systems such as healthcare, and has been driven by failure to improve the safety of patient care by traditional means, despite more than two decades of effort.[8] A complex adaptive system is one with multiple interacting and interdependent parts that change continuously and dynamically in response to environment or conditions.[9] In healthcare, these components consist primarily of humans, such as clinicians, patients and their families, aided by affordances such as technological artefacts and equipment. Human performance is inherently variable; regardless of their experience and ability, for example, the performance of an individual clinician will vary depending on the problem, time of day, and so on. Furthermore, clinicians work in small, medium and large ad hoc teams, and must interact with a range of other healthcare professionals whose performance is also varying. When the variability associated with patients and their illness or injury is also taken into account, the result is a complex and unpredictable system. Due to the complex and dynamic nature of the interactions of components, outcomes from a complex adaptive system can be unexpected and unable to be attributed to specific inputs—this is what is known as emergent behaviour. In addition, the system’s history plays a part in determining where things are now; this is called ‘path dependence’.[10] As RHC grew from the field of resilience engineering, it borrowed from resilience engineering theory, which conceptualises how normal variation in task performance in socio-technical systems can lead to both wanted and unwanted outcomes. This guides research into how variation in human performance of everyday work processes contributes to both failure (i.e. unwanted outcome or ‘error’) and success (i.e. wanted outcome). The theory is grounded in system thinking and complexity science, and in understanding how systems typically cope successfully with unwanted outcomes (or events) that are unexpected. Resilience engineering originated in 2005, at a gathering of influential industrial safety scholars led by Erik Hollnagel, David Woods and Nancy Leveson,[10] and emerged from the work of Crawford Holling on ecological systems[11] and Charles Perrow on normal accidents.[12] The application of resilience R.Clay-WilliamsandJ.Braithwaite /ResilientHealthCare 135