Abstract
BackgroundResilience engineering (RE) is an emerging perspective on safety in complex adaptive systems that emphasises how outcomes emerge from the complexity of the clinical environment. Complexity creates the need for flexible adaptation to achieve outcomes. RE focuses on understanding the nature of adaptations, learning from success and increasing adaptive capacity. Although the philosophy is clear, progress in applying the ideas to quality improvement has been slow. The aim of this study is to test the feasibility of translating RE concepts into practical methods to improve quality by designing, implementing and evaluating interventions based on RE theory. The CARE model operationalises the key concepts and their relationships to guide the empirical investigation.MethodsThe settings are the Emergency Department and the Older Person’s Unit in a large London teaching hospital. Phases 1 and 2 of our work, leading to the development of interventions to improve the quality of care, are described in this paper. Ethical approval has been granted for these phases. Phase 1 will use ethnographic methods, including observation of work practices and interviews with staff, to understand adaptations and outcomes. The findings will be used to collaboratively design, with clinical staff in interactive design workshops, interventions to improve the quality of care. The evaluation phase will be designed and submitted for ethical approval when the outcomes of phases 1 and 2 are known.DiscussionStudy outcomes will be knowledge about the feasibility of applying RE to improve quality, the development of RE theory and a validated model of resilience in clinical work which can be used to guide other applications. Tools, methods and practical guidance for practitioners will also be produced, as well as specific knowledge of the potential effectiveness of the implemented interventions in emergency and older people’s care. Further studies to test the application of RE at a larger scale will be required, including studies of other healthcare settings, organisational contexts and different interventions.
Highlights
Resilience engineering (RE) is an emerging perspective on safety in complex adaptive systems that emphasises how outcomes emerge from the complexity of the clinical environment
The persistence of care quality problems implies that further progress will only be possible if we find more effective quality improvement strategies
The overall aim of this study is to develop and test interventions based on RE principles to improve the quality of care
Summary
The study is based on RE theory and cannot be described as a classic study in the grounded theory tradition, it will adopt grounded theory concepts such as a formative research design, iterative cycles of data collection and analysis, and a focus on theory development [55]. A key aim will be to identify areas of interest for more focused and targeted observations in subsequent sweeps, which will involve in-depth observations of important mechanisms such as handover, multidisciplinary meetings and ward rounds These will be observed by shadowing clinical staff and may involve short discussions and facilitated reflection from staff on aspects of the CARE model. Membership of the advisory groups may change due to staff turnover, shift work and clinical demands The output of this phase will be agreement with clinical leaders and teams and detailed proposals for the interventions to be implemented. Both study units have existing processes for involving patients and the public in designing and reflecting upon care, and these views will be elicited in the intervention design workshops. Intervention development will be completed by the end of 2015, and implementation and evaluation will commence in early 2016 alongside evaluation
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