Emergency Department Escalation in Theory and Practice: A Mixed-Methods Study Using a Model of Organizational Resilience

Do healthcare professionals work around safety standards, and should we be worried? A scoping review

BACKGROUND

Healthcare staff adapt to challenges faced when delivering healthcare by using workarounds. Sometimes, safety standards, the very things used to routinely mitigate risk in healthcare, are the obstacles that staff work around. While workarounds have negative connotations, there is an argument that, in some circumstances, they contribute to the delivery of safe care.

OBJECTIVES

In this scoping review, we explore the circumstances and perceived implications of safety standard workarounds (SSWAs) conducted in the delivery of frontline care.

METHOD

We searched MEDLINE, CINAHL, PsycINFO and Web of Science for articles reporting on the circumstances and perceived implications of SSWAs in healthcare. Data charting was undertaken by two researchers. A narrative synthesis was developed to produce a summary of findings.

RESULTS

We included 27 papers in the review, which reported on workarounds of 21 safety standards. Over half of the papers (59%) described working around standards related to medicine safety. As medication standards featured frequently in papers, SSWAs were reported to be performed by registered nurses in 67% of papers, doctors in 41% of papers and pharmacists in 19% of papers. Organisational causes were the most prominent reason for workarounds.Papers reported on the perceived impact of SSWAs for care quality. At times SSWAs were being used to support the delivery of person-centred, timely, efficient and effective care. Implications of SSWAs for safety were diverse. Some papers reported SSWAs had both positive and negative implications for safety simultaneously. SSWAs were reported to be beneficial for patients more often than they were detrimental.

CONCLUSION

SSWAs are used frequently during the delivery of everyday care, particularly during medication-related processes. These workarounds are often used to balance different risks and, in some circumstances, to achieve safe care.

Quality and reporting of large-scale improvement programmes: a review of maternity initiatives in the English NHS, 2010-2023

BACKGROUND

Large-scale improvement programmes are a frequent response to quality and safety problems in health systems globally, but have mixed impact. The extent to which they meet criteria for programme quality, particularly in relation to transparency of reporting and evaluation, is unclear.

AIM

To identify large-scale improvement programmes focused on intrapartum care implemented in English National Health Service maternity services in the period 2010-2023, and to conduct a structured quality assessment.

METHODS

We drew on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidance to inform the design and reporting of our study. We identified relevant programmes using multiple search strategies of grey literature, research databases and other sources. Programmes that met a prespecified definition of improvement programme, that focused on intrapartum care and that had a retrievable evaluation report were subject to structured assessment using selected features of programme quality.

RESULTS

We identified 1434 records via databases and other sources. 14 major initiatives in English maternity services could not be quality assessed due to lack of a retrievable evaluation report. Quality assessment of the 15 improvement programmes meeting our criteria for assessment found highly variable quality and reporting. Programme specification was variable and mostly low quality. Only eight reported the evidence base for their interventions. Description of implementation support was poor and none reported customisation for challenged services. None reported reduction of inequalities as an explicit goal. Only seven made use of explicit patient and public involvement practices, and only six explicitly used published theories/models/frameworks to guide implementation. Programmes varied in their reporting of the planning, scope and design of evaluation, with weak designs evident.

CONCLUSIONS

Poor transparency of reporting and weak or absent evaluation undermine large-scale improvement programmes by limiting learning and accountability. This review indicates important targets for improving quality in large-scale programmes.

A day in the life of a home care worker in England: A human factors systems perspective

The delivery of home care in England is explored with respect to (a) the work system (b) the barriers that challenge worker performance, and most importantly (c) whether these barriers impact the quality and safety of the care received by older adults. Data were collected using surveys and interviews with home care workers (n = 11). The analysis used two validated Human Factors and Ergonomics (HFE) models to map the data which identified three key performance barriers; (1) time factors, (2) organisational practices, and (3) job design. Adaptive behaviour was identified as being routine to manage time barriers, which resulted in trade-offs between care outcomes (delivery), quality and safety standards and work-related quality of life. The findings make an important contribution to the limited research literature on home care work by highlighting the opportunity for an HFE systems perspective to provide a novel approach for both understanding home care and building better home care systems.

Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies

OBJECTIVE

The objective of this review was to develop a taxonomy of pressures experienced by health services and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies were developed from a review of observational studies directly assessing care delivered in a variety of clinical environments.

DESIGN

In the first phase, a scoping review of the relevant literature was conducted. In the second phase, pressures and strategies were systematically coded from the included papers, and categorised.

DATA SOURCES

Electronic databases (MEDLINE, Embase, CINAHL, PsycInfo and Scopus) and reference lists from recent reviews of the resilient healthcare literature.

ELIGIBILITY CRITERIA

Studies were included from the resilient healthcare literature, which used descriptive methodologies to directly assess a clinical environment. The studies were required to contain strategies for managing under pressure.

RESULTS

5402 potential articles were identified with 17 papers meeting the inclusion criteria. The principal source of pressure described in the studies was the demand for care exceeding capacity (ie, the resources available), which in turn led to difficult working conditions and problems with system functioning. Strategies for responding to pressures were categorised into anticipatory and on-the-day adaptations. Anticipatory strategies included strategies for increasing resources, controlling demand and plans for managing the workload (efficiency strategies, forward planning, monitoring and co-ordination strategies and staff support initiatives). On-the-day adaptations were categorised into: flexing the use of existing resources, prioritising demand and adapting ways of working (leadership, teamwork and communication strategies).

CONCLUSIONS

The review has culminated in an empirically based taxonomy of pressures and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies could help clinicians and managers to optimise how they respond to pressures and may be used as the basis for training programmes and future research evaluating the impact of different strategies.

From Threatening Chaos to Temporary Order through a Complex Process of Adaptation: A Grounded Theory Study of the Escalation of Intensive Care during the COVID-19 Pandemic

To ensure high-quality care, operationalize resilience and fill the knowledge gap regarding how to improve the prerequisites for resilient performance, it is necessary to understand how adaptive capacity unfolds in practice. The main aim of this research was to explain the escalation process of intensive care during the first wave of the pandemic from a microlevel perspective, including expressions of resilient performance, intervening conditions at the micro-meso-macrolevels and short- and long-term consequences. A secondary aim was to provide recommendations regarding how to optimize the prerequisites for resilient performance in intensive care. A grounded theory methodology was used. First-person stories from different healthcare professionals (n70) in two Swedish regions were analyzed using the constant comparative method. This resulted in a novel conceptual model (including 6 main categories and 24 subcategories), and 41 recommendations. The conclusion of these findings is that the escalation of intensive care can be conceptualized as a transition from threatening chaos to temporary order through a complex process of adaptation. To prepare for the future, the components of space, stuff, staff, system and science, with associated continuity plans, must be implemented, anchored and communicated to actors at all levels of the system.

Experience-based codesign approach to improve care in Australian emergency departments for complex consumer cohorts: the MyED project protocol, Stages 1.1-1.3

INTRODUCTION

Emergency department (ED) care must adapt to meet current and future demands. In Australia, ED quality measures (eg, prolonged length of stay, re-presentations or patient experience) are worse for older adults with multiple comorbidities, people who have a disability, those who present with a mental health condition, Indigenous Australians, and those with a culturally and linguistically diverse (CALD) background. Strengthened ED performance relies on understanding the social and systemic barriers and preferences for care of these different cohorts, and identifying viable solutions that may result in sustained improvement by service providers. A collaborative 5-year project (MyED) aims to codesign, with ED users and providers, new or adapted models of care that improve ED performance, improve patient outcomes and improve patient experience for these five cohorts.

METHODS AND ANALYSIS

Experience-based codesign using mixed methods, set in three hospitals in one health district in Australia. This protocol introduces the staged and incremental approach to the whole project, and details the first research elements: ethnographic observations at the ED care interface, interviews with providers and interviews with two patient cohorts-older adults and adults with a CALD background. We aim to sample a diverse range of participants, carefully tailoring recruitment and support.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Western Sydney Local Health District Human Research Ethics Committee (2022/PID02749-2022/ETH02447). Prior informed written consent will be obtained from all research participants. Findings from each stage of the project will be submitted for peer-reviewed publication. Project outputs will be disseminated for implementation more widely across New South Wales, Australia.

An Adlerian-Based Narrative Inquiry of Temporal Awareness, Resilience, and Patient-Centeredness Among Emergency Physicians-The Gyroscope Model

INTRODUCTION

Although extensive research examined time perceptions among patients in the emergency department (ED), studies on temporal awareness among emergency physicians is scant. Salutogenics is the theoretical anchor.

METHODS

The sample comprised ten emergency resident physicians from an Israeli public tertiary hospital. Narrative interviews were conducted. To determine the theme of the study, Adlerian narrative analysis was performed. To identify categories, semantic and content analyses were performed.

RESULTS

Adlerian narrative analysis highlighted temporal awareness as a strong theme across interviews. Semantic and content analyses identified categories within temporal awareness. Analyses revealed a movement among three subcategories: A clinical task in which physicians rapidly shift along seven distinct times, temporal awareness shaping their work experience, and temporal awareness as inhibiting or enabling relationships with patients. Data-analyses identified two groups of physicians, one group driven by the need to control the time to avoid errors, experiencing anxiety and poor wellbeing, and the other, shifting from clinical tasks to patient-centeredness while removing the time factor from their considerations and experiencing resilience through manageability and meaningfulness. We introduce the "gyroscope model" for physicians to illustrate these findings and propose recommendations for practice.

DISCUSSION

Understanding the complexity of the temporal continuum and the influence of shifting from the clinical task to relationships with patients may contribute to resilience of resident physician in the ED and to their self-efficacy, enriching their professional skills and capacity to cope and grow while facing the complexity of the ED.

Complex systems design based on actual system functioning: Coping with variability in a national water ambulances service

BACKGROUND: In Brazil, the Mobile Emergency Medical Service (SAMU) is a model of mobile assistance and care for emergencies standardized throughout the country. The water ambulance service within the SAMU operates in riverside and coastal areas, and faces challenges and peculiarities that increase the complexity of providing a high-quality and safe emergency care service. OBJECTIVE: To develop organizational design guidelines aiming to improve resilient performance of complex systems, with an application to riverine and coastal mobile emergency care in Brazil. METHODS: Data collection followed an ethnographic approach. Fieldwork was carried in a participatory way, based on worksite technical description, semi-structured interviews with managers and emergency care teams’ professionals, and work observation whenever possible. Five regional SAMU coordinations were visited. Data coding employed content analysis and grouped data excerpts according to concepts of capacity and demand. Interfaces were identified between demand and capacity elements and adaptations led by system agents, orienting the proposal of guidelines for organizational design as solutions to face the verified gaps. RESULTS: Design guidelines produced spanned composition and training of both intervention teams and dispatch central teams, uniforms and personal protective equipment (PPE), decentralized water bases, means of communication, intervention protocols, biosafety and inter-sector actions. CONCLUSION: The approach enabled framing and assessment of specific design elements according to resilience engineering concepts, which in turn showed paths for improving the service and reconciling work-as-imagined and actual system functioning.

Making It Work: The Experiences of Delivering a Community Mental Health Service during the COVID-19 Pandemic

The COVID-19 pandemic forced rapid innovative change to healthcare delivery. Understanding the unique challenges faced by staff may contribute to different approaches when managing future pandemics. Qualitative interviews were conducted with 21 staff from a Community Mental Health Team in the North West of England, UK, three months after the first wave of the pandemic. Thematic analysis was used to examine data reporting the challenges arising when working to deliver a service during the pandemic. Data is discussed under four headings; "senior trust managers trying to make it work", "individuals making it work", "making it work as a team", and "making it work through working at home". Clear communication was essential to ensure adherence to guidelines while providing safe care delivery. The initial response to the pandemic involved the imposition of boundaries on staff by senior leadership to ensure that vulnerable service users received a service while maintaining staff safety. The data raises questions about how boundaries were determined, the communication methods employed, and whether the same outcome could have been achieved through involving staff more in decision-making processes. Findings could be used to design interventions to support mental health staff working to deliver community services during future crises.

Understanding complex work using an extension of the resilience CARE model: an ethnographic study

Background

Resilient Healthcare research centres on understanding and improving quality and safety in healthcare. The Concepts for Applying Resilience Engineering (CARE) model highlights the relationships between demand, capacity, work-as-done, work-as-imagined, and outcomes, all of which are central aspects of Resilient Healthcare theory. However, detailed descriptions of the nature of misalignments and the mechanisms used to adapt to them are still unknown.

Objective

The objectives were to identify and classify types of misalignments between demand and capacity and types of adaptations that were made in response to misalignments.

Methods

The study involved 88.5 hours of non-participant ethnographic observations in a large, teaching hospital in central London. The wards included in the study were: two surgical wards, an older adult ward, a critical care unit, and the Acute Assessment Unit (AAU), an extension unit created to expedite patient flow out of the Emergency Department. Data were collected via observations of routine clinical work and ethnographic interviews with healthcare professionals during the observations. Field notes were transcribed and thematically analysed using a combined deductive-inductive approach based on the CARE model.

Results

A total of 365 instances of demand-capacity misalignment were identified across the five wards included in the study. Of these, 212 had at least one observed corresponding work adaptation. Misalignments identified include equipment, staffing, process, communication, workflow, and space. Adaptations identified include process, resource redistribution, and extra-role performance. For all misalignment types observed across the five in-patient settings, process adaptations were the most frequently used adaptations. The exception to this was for staffing misalignments, which were most frequently responded to with extra-role performance adaptations. Of the three process adaptations, hospital workers most often adapted by changing how the process was done.

Conclusions

This study contributes a new version of the CARE model that includes types of misalignments and corresponding adaptations, which can be used to better understand work-as-done. This affords insight into the complexity of the system and how it might be improved by reducing misalignments via work system redesign or by enhancing adaptive capacity.

Using video reflexive ethnography to explore the use of variable rate intravenous insulin infusions

Background

The use of variable rate intravenous insulin infusion (VRIII) is a complex process that has consistently been implicated in reports of error and consequent harm. Investment in patient safety has focused mainly on learning from errors, though this has yet to be proved to reduce error rates. The Resilient Health Care approach advocates learning from everyday practices. Video reflexive ethnography (VRE) is an innovative methodology used to capture everyday practices, reflect on and thereby improve these. This study set out to explore the use of VRIIIs by utilising the VRE methodology.

Methods

This study was conducted in a Vascular Surgery Unit. VRE methodology was used to collect qualitative data that involved videoing healthcare practitioners caring for patients treated with VRIII and discussing the resulting clips with participants in reflexive meetings. Transcripts of these were subjected to thematic analysis. Quantitative data (e.g. blood glucose measurements) were collected from electronic patient records in order to contextualise the outcomes of the video-observed tasks.

Results

The use of VRE in conjunction with quantitative data revealed that context-dependent adaptations (seeking verbal orders to treat hypoglycaemia) and standardised practices (using VRIII guidelines) were strategies used in everyday work. Reflexive meetings highlighted the challenges faced while using VRIII, which were mainly related to lack of clinical knowledge, e.g. prescribing/continuing long-acting insulin analogues alongside the VRIII, and problems with organisational infrastructure, i.e. the wireless blood glucose meter results sometimes not updating on the electronic system. Reflexive meetings also enabled participants to share the meanings of the reality surrounding them and encouraged them to suggest solutions tailored to their work, for example face-to-face, VRIII-focused training.

Conclusions

VRE deepened understanding of VRIII by shedding light on its essential tasks and the challenges and adaptations entailed by its use. Future research might focus on collecting data across various units and hospitals to develop a full picture of the use of VRIIIs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07883-w.

An Integrated Data Mining Framework for Organizational Resilience Assessment and Quality Management Optimization in Trauma Centers

Every second counts for patients with life-threatening injuries, and trauma centers deliver timely emergency care to patients with traumatic injuries. Quality assessment and improvement are some of the most fundamental concerns in trauma centers. In this study, a comprehensive organizational resilience approach is proposed to evaluate performance in trauma centers using the European Foundation for Quality Management as a fundamental and strategic approach. We propose a unique intelligent algorithm composed of parametric and non-parametric statistical methods to determine the type and the extent of influence within the organizational resilience and quality management perspectives. We use structural equation modeling to examine the reliability and validity of the input data. The efficiency of each trauma center is then measured using a machine learning method with genetic programming, support vector regression, and Gaussian process regression. The mean absolute percentage error is used to determine the optimal model, and a fuzzy data envelopment analysis model is used to verify and validate the results obtained from the optimal model. The results show that customer results, human capital results, and key performance results have the highest importance weights and positive influence on quality management. Cognitive resources, roles and responsibilities, and self-organization have the highest importance weights and positive influence on organizational resilience.

Rethinking preparedness planning in disaster emergency care: lessons from a beyond-surge-capacity event

Background

Large-scale burn disasters can produce casualties that threaten medical care systems. This study proposes a new approach for developing hospital readiness and preparedness plan for these challenging beyond-surge-capacity events.

Methods

The Formosa Fun Coast Dust Explosion (FFCDE) was studied. Data collection consisted of in-depth interviews with clinicians from four initial receiving hospitals and their relevant hospital records. A detailed timeline of patient flow and emergency department (ED) workload changes of individual hospitals were examined to build the EDs' overload patterns. Data analysis of the multiple hospitals' responses involved chronological process-tracing analysis, synthesis, and comparison analysis in developing an integrated adaptations framework.

Results

A four-level ED overload pattern was constructed. It provided a synthesis of specifics on patient load changes and the process by which hospitals' surge capacity was overwhelmed over time. Correspondingly, an integrated 19 adaptations framework presenting holistic interrelations between adaptations was developed. Hospitals can utilize the overload patterns and overload metrics to design new scenarios with diverse demands for surge capacity. The framework can serve as an auxiliary tool for directive planning and cross-check to address the insufficiencies of preparedness plans.

Conclusions

The study examined a wide-range spectrum of emergency care responses to the FFCDE. It indicated that solely depending on policies or guidelines for preparedness plans did not contribute real readiness to MCIs. Hospitals can use the study's findings and proposal to rethink preparedness planning for the future beyond surge capacity events.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-021-00403-x.

Forecasting the Requirement for Nonelective Hospital Beds in the National Health Service of the United Kingdom: Model Development Study

BACKGROUND

Over the last decade, increasing numbers of emergency department attendances and an even greater increase in emergency admissions have placed severe strain on the bed capacity of the National Health Service (NHS) of the United Kingdom. The result has been overcrowded emergency departments with patients experiencing long wait times for admission to an appropriate hospital bed. Nevertheless, scheduling issues can still result in significant underutilization of bed capacity. Bed occupancy rates may not correlate well with bed availability. More accurate and reliable long-term prediction of bed requirements will help anticipate the future needs of a hospital's catchment population, thus resulting in greater efficiencies and better patient care.

OBJECTIVE

This study aimed to evaluate widely used automated time-series forecasting techniques to predict short-term daily nonelective bed occupancy at all trusts in the NHS. These techniques were used to develop a simple yet accurate national health system-level forecasting framework that can be utilized at a low cost and by health care administrators who do not have statistical modeling expertise.

METHODS

Bed occupancy models that accounted for patterns in occupancy were created for each trust in the NHS. Daily nonelective midnight trust occupancy data from April 2011 to March 2017 for 121 NHS trusts were utilized to generate these models. Forecasts were generated using the three most widely used automated forecasting techniques: exponential smoothing; Seasonal Autoregressive Integrated Moving Average; and Trigonometric, Box-Cox transform, autoregressive moving average errors, and Trend and Seasonal components. The NHS Modernisation Agency's recommended forecasting method prior to 2020 was also replicated.

RESULTS

The accuracy of the models varied on the basis of the season during which occupancy was forecasted. For the summer season, percent root-mean-square error values for each model remained relatively stable across the 6 forecasted weeks. However, only the trend and seasonal components model (median error=2.45% for 6 weeks) outperformed the NHS Modernisation Agency's recommended method (median error=2.63% for 6 weeks). In contrast, during the winter season, the percent root-mean-square error values increased as we forecasted further into the future. Exponential smoothing generated the most accurate forecasts (median error=4.91% over 4 weeks), but all models outperformed the NHS Modernisation Agency's recommended method prior to 2020 (median error=8.5% over 4 weeks).

CONCLUSIONS

It is possible to create automated models, similar to those recently published by the NHS, which can be used at a hospital level for a large national health care system to predict nonelective bed admissions and thus schedule elective procedures.

Health system resilience: a literature review of empirical research

The concept of health system resilience has gained popularity in the global health discourse, featuring in UN policies, academic articles and conferences. While substantial effort has gone into the conceptualization of health system resilience, there has been no review of how the concept has been operationalized in empirical studies. We conducted an empirical review in three databases using systematic methods. Findings were synthesized using descriptive quantitative analysis and by mapping aims, findings, underlying concepts and measurement approaches according to the resilience definition by Blanchet et al. We identified 71 empirical studies on health system resilience from 2008 to 2019, with an increase in literature in recent years (62% of studies published since 2017). Most studies addressed a specific crisis or challenge (82%), most notably infectious disease outbreaks (20%), natural disasters (15%) and climate change (11%). A large proportion of studies focused on service delivery (48%), while other health system building blocks were side-lined. The studies differed in terms of their disciplinary tradition and conceptual background, which was reflected in the variety of concepts and measurement approaches used. Despite extensive theoretical work on the domains which constitute health system resilience, we found that most of the empirical literature only addressed particular aspects related to absorptive and adaptive capacities, with legitimacy of institutions and transformative resilience seldom addressed. Qualitative and mixed methods research captured a broader range of resilience domains than quantitative research. The review shows that the way in which resilience is currently applied in the empirical literature does not match its theoretical foundations. In order to do justice to the complexities of the resilience concept, knowledge from both quantitative and qualitative research traditions should be integrated in a comprehensive assessment framework. Only then will the theoretical ‘resilience idea’ be able to prove its usefulness for the research community.

Adapting to the unexpected: Problematic work situations and resilience strategies in healthcare institutions during the COVID-19 pandemic's first wave

The COVID-19 pandemic's first wave required considerable adaptation efforts on the part of healthcare workers. The literature on resilient healthcare describes how the collective regulation strategies implemented by frontline employees make essential contributions to institutions' abilities to cope with major crises. The present mixed-methodology study was thus conducted among a large sample of employees in a variety of Swiss healthcare institutions and focused on problematic real-world situations experienced by them and their managers during the pandemic's first wave. It highlighted the anticipatory and adaptive strategies implemented by institutions, teams and individuals. The most frequently cited problematic situations involved organisational changes, interpersonal conflicts and workloads. In addition to the numerous top-down measures implemented by institutions, respondents also identified personal or team regulation strategies such as increasing staff flexibility, prioritising tasks, interprofessional collaboration, peer support or creating new communication channels to families. The present findings underlined the importance of taking greater account of healthcare support staff and strengthening managerial capacity to support interprofessional teams including those support staff.

Emergency care under the magnifying glass: a review of ethnographic studies in the scientific literature on hospital emergency services

The article presents a review of ethnographic studies in the scientific literature on hospital emergency services, with the objective of systematizing the studies and their principal findings, referring to the health-disease-healthcare process in hospital emergency services from an ethnographic perspective. An integrative literature review was performed of studies published in Argentine and international indexed journals and in the following electronic databases: PubMed, VHL, Scopus, Redalyc, and SciELO. The corpus of the analysis consisted of a total of 69 articles, which were submitted to content analysis, having identified the following analytical dimensions: quality of care, communication and bonds, subjectivity, application of information technologies, methodological reflection, patients' experiences and practices, decision-making, and violence. The results allowed identifying a process that differs from guidelines and protocols, in which healthcare workers' subjective aspects, communication and interpersonal relations, and working conditions shape, orient, and condition the treatment and care provided in the hospital. The article thus highlights the approach to subjective aspects in health studies, to understand not only health workers' perspectives and experiences but also the persistent barriers to providing better quality of care, complexifying a problem ignored by a large share of the analyses.

Multilevel influences on resilient healthcare in six countries: an international comparative study protocol

INTRODUCTION

Resilient healthcare (RHC) is an emerging area of theory and applied research to understand how healthcare organisations cope with the dynamic, variable and demanding environments in which they operate, based on insights from complexity and systems theory. Understanding adaptive capacity has been a focus of RHC studies. Previous studies clearly show why adaptations are necessary and document the successful adaptive actions taken by clinicians. To our knowledge, however, no studies have thus far compared RHC across different teams and countries. There are gaps in the research knowledge related to the multilevel nature of resilience across healthcare systems and the team-based nature of adaptive capacity.This cross-country comparative study therefore aims to add knowledge of how resilience is enabled in diverse healthcare systems by examining adaptive capacity in hospital teams in six countries. The study will identify how team, organisational and national healthcare system factors support or hinder the ability of teams to adapt to variability and change. Findings from this study are anticipated to provide insights to inform the design of RHC systems by considering how macro-level and meso-level structures support adaptive capacity at the micro-level, and to develop guidance for organisations and policymakers.

METHODS AND ANALYSIS

The study will employ a multiple comparative case study design of teams nested within hospitals, in turn embedded within six countries: Australia, Japan, the Netherlands, Norway, Switzerland and the UK. The design will be based on the Adaptive Teams Framework placing adaptive teams at the centre of the healthcare system with layers of environmental, organisational and system level factors shaping adaptive capacity. In each of the six countries, a focused mapping of the macro-level features of the healthcare system will be undertaken by using documentary sources and interviews with key informants operating at the macro-level.A sampling framework will be developed to select two hospitals in each country to ensure variability based on size, location and teaching status. Four teams will be selected in each hospital-one each of a structural, hybrid, responsive and coordinating team. A total of eight teams will be studied in each country, creating a total sample of 48 teams. Data collection methods will be observations, interviews and document analysis. Within-case analysis will be conducted according to a standardised template using a combination of deductive and inductive qualitative coding, and cross-case analysis will be conducted drawing on the Qualitative Comparative Analysis framework.

ETHICS AND DISSEMINATION

The overall Resilience in Healthcare research programme of which this study is a part has been granted ethical approval by the Norwegian Centre for Research Data (Ref. No. 8643334 and Ref. No. 478838). Ethical approval will also be sought in each country involved in the study according to their respective regulatory procedures. Country-specific reports of study outcomes will be produced for dissemination online. A collection of case study summaries will be made freely available, translated into multiple languages. Brief policy communications will be produced to inform policymakers and regulators about the study results and to facilitate translation into practice. Academic dissemination will occur through publication in journals specialising in health services research. Findings will be presented at academic, policy and practitioner conferences, including the annual RHC Network meeting and other healthcare quality and safety conferences. Presentations at practitioner and academic conferences will include workshops to translate the findings into practice and influence quality and safety programmes internationally.

Resilience in a prehospital setting - a new focus for future research?

Background

Handling and initiating of treatment in a prehospital setting are complex processes that involve many treatment options and include several parts of the chain of survival. Capacity to adapt to unexpected changes in the patients’ conditions or in the surroundings is a prerequisite for patient safety. Outside the healthcare sector, safety science is moving from an approach focused on the analysis and management of error (Safety I) to instead understanding the inherent properties of safety systems (Safety II). In healthcare the attention to why service providers are able to succeed under challenging conditions remains sparse. The aim of this commentary is to give a better understanding of how the concept and inclusion of resilience can inspire a new approach for future research in prehospital settings. So far, most resilience studies have been conducted in emergency departments while the role of contextual factors and adaptations in a prehospital setting has remained unexplored.

Main body

In contrast to traditional research on healthcare quality and safety, which tends to focus on failures, resilience research is interested in examining the overwhelming majority of healthcare processes with successful outcomes, to determine how high-quality patient care is generated. Resilience is conceptualized as a proactive ability to adjust to potentially harmful influences and challenges rather than to resist them. To better understand and promote resilience, there is a need to explore the underlying mechanisms of adaptation, trade-offs and improvisation that occur in the emergency chain. Attention to how people respond to disruptions, challenges and opportunities is vital. There are factors, recognized and unidentified, influencing adaptation, trade-offs and improvisation. Influencing factors at different levels could be of particular value to increase knowledge to better understand resilience in a practical perspective. As prehospital work conditions are highly unpredictable and diverse, learning through everyday work could be of great value if the experiences are transferred and integrated in training and simulation.

Conclusions

Empirical research is of crucial importance to build and support resilient systems and processes in a prehospital setting. We need a new framework and a new approach to how research on this topic is conducted and to support resilient performance. This should involve identifying factors that promote resilience, both on individual-, team- and system- levels.

Measurement of resilience potential - development of a resilience assessment grid for emergency departments

BACKGROUND

Resilience engineering has been advocated as an alternative to the management of safety over the last decade in many domains. However, to facilitate metrics for measuring and helping analyze the resilience potential for emergency departments (EDs) remains a significant challenge. The study aims to redesign the Hollnagel's resilience assessment grid (RAG) into a custom-made RAG (ED-RAG) to support resilience management in EDs.

METHODS

The study approach had three parts: 1) translation of Hollnagel's RAG into Chinese version, followed by generation of a tailored set of ED-RAG questions adapted to EDs; 2) testing and revising the tailored sets until to achieve satisfactory validity for application; 3) design of a new rating scale and scoring method. The test criteria of the ED-RAG questionnaire adopted the modified three-level scoring criteria proposed by Bloom and Fischer. The study setting of the field test is a private regional hospital.

RESULTS

The fifth version of ED-RAG was acceptable after a field test. It has three sets of open structured questions for the potentials to respond, monitor, and anticipate, and a set of structured questions for the potential to learn. It contained 38 questions corresponding to 32 foci. A new 4-level rating scale along with a novel scaling method can improve the scores conversion validity and communication between team members and across investigations. This final version is set to complete an interview for around 2 hours.

CONCLUSIONS

The ED-RAG represents a snapshot of EDs'resilience under specific conditions. It might be performed multiple times by a single hospital to monitor the directions and contents of improvement that can supplement conventional safety management toward resilience. Some considerations are required to be successful when hospitals use it. Future studies to overcome the potential methodological weaknesses of the ED-RAG are needed.

Operationalizing resilient healthcare concepts through a serious video game for clinicians

Resilient healthcare emphasises the importance of adaptive capacity in quality healthcare. This theory has had extensive theoretical development, but comparatively limited translation for clinicians in practice. This study is the first to present resilient healthcare principles in a serious video game. Serious games are an effective tool for engaging users, sharing ideas and eliciting reflections. The aim of this study was to communicate principles from resilient healthcare to clinicians through a serious video game, and to evaluate the game's feasibility as a prompt to reflect on practice. The game, Resilience Challenge, is scenario-based and requires players to resolve dilemmas in clinical practice. It was disseminated online, and was played 1949 times during the four-month study. The game was evaluated using an immediate cross-sectional survey, which included both Likert-style and free text responses. Participants reported that the game was engaging (93%) and that they would recommend it to others (89%). Fewer participants reported learning about resilient healthcare concepts (64%). Resilience Challenge is a promising way to prompt reflections about clinical work, and demonstrates mixed outcomes in communicating resilient healthcare principles to clinicians.

Defining adaptive capacity in healthcare: A new framework for researching resilient performance

Resilience principles show promise for improving the quality of healthcare, but there is a need for further theoretical development to include all levels and scales of activity across the whole healthcare system. Many existing models based on engineering concepts do not adequately address the prominence of social, cultural and organisational factors in healthcare work. Promising theoretical developments include the four resilience potentials, the CARE model and the Moments of Resilience Model, but they are all under specified and in need of further elaboration. This paper presents the Integrated Resilience Attributes Framework in which these three theoretical perspectives are integrated to provide examples of anticipating, responding, monitoring and learning at different scales of time and space. The framework is intended to guide researchers in researching resilience, especially the linkages between resilience at different scales of time and space across the whole healthcare system.

Using Safety-II and resilient healthcare principles to learn from Never Events

OBJECTIVES

Conduct a secondary analysis of root cause analysis (RCA) reports of Never Events to determine whether and how Safety-II/resilient healthcare principles could contribute to improving the quality of investigation reports and therefore preventing future Never Events.

DESIGN

Qualitative and quantitative retrospective analysis of RCA reports.

SETTING

A large acute healthcare Trust in London.

PARTICIPANTS

None.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Quality of RCA reports, robustness of actions proposed.

RESULTS

RCA reports had low-to-moderate effectiveness ratings and low resilience ratings. Reports identified many system vulnerabilities that were not addressed in the actions proposed. Using a Safety-II/resilient healthcare lens to examine work-as-done and misalignments between demand and capacity would strengthen analysis of Never Events.

CONCLUSION

Safety-II/Resilient Healthcare concepts can increase the quality of RCA reports and focus attention on prospectively strengthening systems. Recommendations for incorporating Safety-II concepts into RCA processes are provided.

A systematic review and meta-synthesis of policy intervention characteristics that influence the implementation of government-directed policy in the hospital setting: implications for infection prevention and control

Background

Government-directed policy plays an important role in the regulation and supervision of healthcare quality. Effective implementation of these policies has the potential to significantly improve clinical practice and patient outcomes, including the prevention of healthcare-associated infections. A systematic review of research describing the implementation of government-directed policy in the hospital setting was performed with the aim to identify policy intervention characteristics that influence implementation.

Methods

A systematic search of four electronic databases was undertaken to identify eligible articles published between 2007 and 2017. Studies were included if published in the English language and described the implementation of government-directed policy in a high-income country hospital setting. Data on policy and implementation were extracted for each article and interpretive syntheses performed.

Results

A total of 925 articles were retrieved and titles and abstracts reviewed, with 69 articles included after review of abstract and full text. Qualitative synthesis of implementation data showed three overarching themes related to intervention characteristics associated with implementation: clarity; infrastructure; and alignment.

Conclusion

Better understanding and consideration of policy intervention characteristics during development and planning will facilitate more effective implementation although research describing implementation of government-directed policy in the hospital setting is limited and of variable quality. The findings of this study provide guidance to staff tasked with the development or implementation of government-directed policy in the hospital setting, infection prevention and control professionals seeking to maximise the impact of policy on practice and improve patient outcomes.

Resilient Health Care: a systematic review of conceptualisations, study methods and factors that develop resilience

BACKGROUND

Traditional approaches to safety management in health care have focused primarily on counting errors and understanding how things go wrong. Resilient Health Care (RHC) provides an alternative complementary perspective of learning from incidents and understanding how, most of the time, work is safe. The aim of this review was to identify how RHC is conceptualised, described and interpreted in the published literature, to describe the methods used to study RHC, and to identify factors that develop RHC.

METHODS

Electronic searches of PubMed, Scopus and Cochrane databases were performed to identify relevant peer-reviewed studies, and a hand search undertaken for studies published in books that explained how RHC as a concept has been interpreted, what methods have been used to study it, and what factors have been important to its development. Studies were evaluated independently by two researchers. Data was synthesised using a thematic approach.

RESULTS

Thirty-six studies were included; they shared similar descriptions of RHC which was the ability to adjust its functioning prior to, during, or following events and thereby sustain required operations under both expected and unexpected conditions. Qualitative methods were mainly used to study RHC. Two types of data sources have been used: direct (e.g. focus groups and surveys) and indirect (e.g. observations and simulations) data sources. Most of the tools for studying RHC were developed based on predefined resilient constructs and have been categorised into three categories: performance variability and Work As Done, cornerstone capabilities for resilience, and integration with other safety management paradigms. Tools for studying RHC currently exist but have yet to be fully implemented. Effective team relationships, trade-offs and health care 'resilience' training of health care professionals were factors used to develop RHC.

CONCLUSIONS

Although there was consistency in the conceptualisation of RHC, methods used to study and the factors used to develop it, several questions remain to be answered before a gold standard strategy for studying RHC can confidently be identified. These include operationalising RHC assessment methods in multi-level and diverse settings and developing, testing and evaluating interventions to address the wider safety implications of RHC amidst organisational and institutional change.

Development of a hospital early warning score to end 'escalation fatigue'

The Antrim Area Hospital Early Warning Score (HEWS) is an innovative method of assessing the level of pressure on an acute hospital site. It combines eight indicators to produce a score from 0 to 49, which is mapped to an escalation category, ranging from low to extreme pressure. The top two categories, 'severe' and 'extreme', have a corresponding range of escalation actions across service areas. This article explains why the Antrim Area HEWS was developed and the issues it sought to address, including 'escalation fatigue' among staff because of the normalisation of high alert status. The article includes an analysis of Antrim Area HEWS data collected over one year. It discusses the benefits of the Antrim Area HEWS including: the provision of a simple, objective method for assessing site pressure; increased awareness of site pressure among various service areas; enhanced staff support and understanding of the need for effective escalation; and the development of a focused and meaningful approach that has overcome the escalation fatigue associated with previous escalation frameworks.

An interview analysis of coordination behaviours in Out-of-Hours secondary care

This paper seeks to elicit and structure the factors that shape the execution and, in particular, the coordination of work in Out of Hours care. Evenings and weekends in UK hospitals are managed by specific Out of Hours (OoH) care arrangements, and associated technology. Managing care within the constraints of staff availability and demands is a key concern for both patient care and staff wellbeing, yet has received little attention from healthcare human factors. A study of sixteen clinical staff used Critical Decision Method to understand how work is coordinated and the constraints and criteria that are applied by the roles managing OoH care. The analysis identified ten types of coordination decision that, in turn, underpinned three types of adaptive behaviour - pre-emption, information augmentation and self-organisation - that were crucial for the effective performance in OoH care. These behaviours explain how OoH staff manage the task demands placed on them, individually and as a team.

Coping With a Mass Casualty: Insights into a Hospital's Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion

OBJECTIVE

The study provides a comprehensive insight into how an initial receiving hospital without adequate capacity adapted to coping with a mass casualty incident after the Formosa Fun Coast Dust Explosion (FFCDE).

METHODS

Data collection was via in-depth interviews with 11 key participants. This was combined with information from medical records of FFCDE patients and admission logs from the emergency department (ED) to build a detailed timeline of patients flow and ED workload changes. Process tracing analysis focused on how the ED and other units adapted to coping with the difficulties created by the patient surge.

RESULTS

The hospital treated 30 victims with 36.3% average total body surface area burn for over 5 hours alongside 35 non-FFCDE patients. Overwhelming demand resulted in the saturation of ED space and intensive care unit beds, exhaustion of critical materials, and near-saturation of clinicians. The hospital reconfigured human and physical resources differently from conventional drills. Graphical timelines illustrate anticipatory or reactive adaptations. The hospital's ability to adapt was based on anticipation during uncertainty and coordination across roles and units to keep pace with varying demands.

CONCLUSION

Adapting to beyond-surge capacity incident is essential to effective disaster response. Building organizational support for effective adaptation is critical for disaster planning.

What is full capacity protocol, and how is it implemented successfully?

Background

Full capacity protocol (FCP) is an internationally recognized intervention designed to address emergency department (ED) crowding. Despite FCP international recognition and positive effects on hospital performance measures, many hospitals, even the most crowded ones, have not implemented FCP. We conducted this study to identify the core components of FCP, explore the key barriers and facilitators associated with the FCP implementation, and provide practical recommendations on how to overcome those barriers.

Methods

To identify the core components of FCP, we used a non-experimental approach. We conducted semi-structured interviews with key informants (e.g., division chiefs, medical directors) involved in the implementation of FCP. We used the Consolidated Framework for Implementation Research (CFIR) to guide data collection and analysis. We used a template analysis approach to determine the relevance of the CFIR constructs to implementing the FCP. We analyzed the responses to the interview questions about FCP definition and FCP key principles, compared different hospitals’ FCP official documents, and consulted with the original FCP developer. We then used an adaptation framework to categorize the core components of FCP into three main groups. Finally, we summarized practical recommendations for each barrier based on information provided by the interviewees.

Results

A total of 32 interviews were conducted. We observed that FCP has evolved from the idea of transferring boarded patients from ED hallways to inpatient hallways to a practical hospital-wide intervention with several components and multiple levels. The key determinant of successful FCP implementation was collaboration with inpatient nursing staff, as they were often reluctant to have patients boarded in inpatient hallways. Other determinants of successful FCP implementation were reaching consensus about the criteria for activation of each FCP level and actions in each FCP level, modifying the electronic health records system, restructuring the inpatient units to have adequate staffing and resources, complying with external regulations and policies such as fire marshal guidelines, and gaining hospital leaders’ support.

Conclusions

The key determinant in implementing FCP is creating a supportive and cooperative hospital culture and encouraging key stakeholders, including inpatient nursing staff, to acknowledge that crowding is a hospital-wide problem that requires a hospital-wide response.

Electronic supplementary material

The online version of this article (10.1186/s13012-019-0925-z) contains supplementary material, which is available to authorized users.

Understanding safety differently: developing a model of resilience in the use of intravenous insulin infusions in hospital in-patients-a feasibility study protocol

BACKGROUND

Intravenous insulin infusions are considered the treatment of choice for critically ill patients and non-critically ill patients with persistent raised blood glucose who are unable to eat, to achieve optimal blood glucose levels. The benefits of using intravenous insulin infusions as well as the problems experienced are well described in the scientific literature. Traditional approaches for improving patient safety have focused on identifying errors, understanding their causes and designing solutions to prevent them. Such approaches do not take into account the complex nature of healthcare systems, which cannot be controlled solely by following standards. An emerging approach called Resilient Healthcare proposes that, to improve safety, it is necessary to focus on how work can be performed successfully as well as how work has failed.

METHODS AND ANALYSIS

The study will be conducted at Oxford University Hospitals NHS Foundation Trust and will involve three phases. Phase I: explore how work is imagined by analysing intravenous insulin infusion guidelines and conducting focus group discussions with guidelines developers, managers and healthcare practitioners. Phase II: explore the interplay between how work is imagined and how work is performed using mixed methods. Quantitative data will include blood glucose levels, insulin infusion rates, number of hypoglycaemic and hyperglycaemic events from patients' electronic records. Qualitative data will include video reflexive ethnography: video recording healthcare practitioners using intravenous insulin infusions and then conducting reflexive meetings with them to discuss selected video footage. Phase III: compare findings from phase I and phase II to develop a model for using intravenous insulin infusions.

ETHICS AND DISSEMINATION

Ethical approvals have been granted by the South Central-Oxford C Research Ethics Committee, Oxford University Hospitals NHS Foundation Trust and University of Reading. The results will be disseminated through presentations at appropriate conferences and meetings, and publications in peer-reviewed journals.

Beyond surge: Coping with mass burn casualty in the closest hospital to the Formosa Fun Coast Dust Explosion

PURPOSE

To provide an insight into the challenges faced by the closest hospital to the Formosa Fun Coast Dust Explosion (FFCDE) disaster scene, and to examine how the hospital staff adapted to cope with the mass burn casualty (MBC) in their overcrowded emergency department (ED) after the disaster.

MATERIAL AND METHODS

The critical incident technique was used for the investigation. Data was gathered through in-depth individual interviews with 15 key participants in this event. The interview data was combined with the medical records of the FFCDE patients and admission logs to build a detailed timeline of ED workload. Process tracing analysis was used to evaluate how the ED and other units adapted to deal with actual and potential bottlenecks created by the patient surge.

RESULTS

Fifty-eight burn patients were treated and registered in approximately six hours while the ED managed 43 non-FFCDE patients. Forty-four patients with average total body surface area burn 51.3% were admitted. Twenty burn patients were intubated. The overwhelming demand created shortages primarily of clinicians, ED space, stretchers, ICU beds, and critical medical materials for burn care. Adaptive activities for the initial resuscitation are identified and synthesized into three typical adaptation patterns. These adaptations were never previously adopted in ED normal practices for daily surge nor in periodical exercises. The analysis revealed adaptation stemmed from the dynamic re-planning and coordination across roles and units and the anticipation of bottlenecks ahead.

CONCLUSION

In the hospital closest to the FFCDE disaster scene, it caused an overwhelming demand in an already crowded, beyond-nominal-capacity ED. This study describes how the hospital mobilized and reconfigured response capacity to cope with overload, uncertainty, and time pressure. These findings support improving disaster planning and preparedness for all healthcare entities through organizational support for adaptation and routine practice coping with unexpected scenarios.

A Safety-II Perspective on Organisational Learning in Healthcare Organisations Comment on "False Dawns and New Horizons in Patient Safety Research and Practice"

In their recent editorial Mannion and Braithwaite provide an insightful critique of traditional patient safety improvement efforts, and offer a powerful alternative vision based on Safety-II thinking that has the potential to radically transform the way we approach patient safety. In this commentary, I explore how the Safety-II perspective points to new directions for organisational learning in healthcare organisations. Current approaches to organisational learning adopted by healthcare organisations have had limited success in improving patient safety. I argue that these approaches learn about the wrong things, and in the wrong way. I conclude that organisational learning in healthcare organisations should provide deeper understanding of the adaptations healthcare workers make in their everyday clinical work, and that learning and improvement approaches should be more democratic by promoting participation and ownership among a broader range of stakeholders as well as patients.