Resilience markers for safer systems and organisations

If computer systems are to be designed to foster resilient performance it is important to be able to identify contributors to resilience. The emerging practice of Resilience Engineering has identified that people are still a primary source of resilience, and that the design of distributed systems should provide ways of helping people and organisations to cope with complexity. Although resilience has been identified as a desired property, researchers and practitioners do not have a clear understanding of what manifestations of resilience look like. This paper discusses some examples of strategies that people can adopt that improve the resilience of a system. Critically, analysis reveals that the generation of these strategies is only possible if the system facilitates them. As an example, this paper discusses practices, such as reflection, that are known to encourage resilient behavior in people. Reflection allows systems to better prepare for oncoming demands. We show that contributors to the practice of reflection manifest themselves at different levels of abstraction: from individual strategies to practices in, for example, control room environments. The analysis of interaction at these levels enables resilient properties of a system to be ‘seen’, so that systems can be designed to explicitly support them. We then present an analysis of resilience at an organisational level within the nuclear domain. This highlights some of the challenges facing the Resilience Engineering approach and the need for using a collective language to articulate knowledge of resilient practices across domains

Safer clinical systems : interim report, August 2010

Safer Clinical Systems is the Health Foundation’s new five year programme of work to test and demonstrate ways to improve healthcare systems and processes, to develop safer systems that improve patient safety. It builds on learning from the Safer Patients Initiative (SPI) and models of system improvement from both healthcare and other industries. Learning from the SPI highlighted the need to take a clinical systems approach to improving safety. SPI highlighted that many hospitals struggle to implement improvement in clinical areas due to inherent problems with support mechanisms. Clinical processes and systems, rather than individuals, are often the contributors to breakdown in patient safety. The Safer Clinical Systems programme aimed to measure the reliability of clinical processes, identify defects within those processes, and identify the systems that result in those defects. Methods to improve system reliability were then to be tested and re-developed in order to reduce the risk of harm being caused to patients. Such system-level awareness should lead to improvements in other patient care pathways. The relationship between system reliability and actual harm is challenging to identify and measure. Specific, well-defined, small-scale processes have been used in other programmes, and system reliability has been shown to have a direct causal relationship with harm (e.g. care bundle compliance in an intensive care unit can reduce the incidence of ventilator-associated pneumonia). However, it has become evident that harm can be caused by a variety of factors over time; when working in broader, more complex and dynamic systems, change in outcome can be difficult to attribute to specific improvements and difficulties are also associated with relating evidence to resulting harm. The overall aim of Phase 1 of the Safer Clinical Systems programme was to demonstrate proof-of-concept that using a systems-based approach could contribute to improved patient safety. In Phase 1, experienced NHS teams from four locations worked together with expert advisers to co-design the Safer Clinical Systems programme

Exploring the importance of reflection in the control room

While currently difficult to measure or explicitly design for, evidence suggests that providing people with opportunities to reflect on experience must be recognized and valued during safety-critical work. We provide an insight into reflection as a mechanism that can help to maintain both individual and team goals. In the control room, reflection can be task-based, critical for the 'smooth' day-to-day operational performance of a socio-technical system, or can foster learning and organisational change by enabling new understandings gained from experience. In this position paper we argue that technology should be designed to support the reflective capacity of people. There are many interaction designs and artefacts that aim to support problem-solving, but very few that support self-reflection and group reflection. Traditional paradigms for safety-critical systems have focussed on ensuring the functional correctness of designs, minimising the time to complete tasks, etc. Work in the area of user experience design may be of increasing relevance when generating artefacts that aim to encourage reflection

Learning Lessons from Controlled Studies to Investigate Users' Resilience Strategies

This work describes the development and implementation of a controlled study into the way users form and utilise resilience strategies to overcome threats to performance. Despite a carefully considered design, participants demonstrated creative and unanticipated strategies to overcome deliberately ‘designed-in’ challenges in our task, thus circumventing the errors and responses we had predicted. We discuss the variety of unanticipated resilience strategies we observed during the course of this study, as well as methodological lessons learned as a result. Furthermore, we describe a forthcoming study which seeks to build upon the initial investigation, utilising a revised task paradigm to address and overcome its limitations

A less disastrous disaster: Managing response to climate-driven hazards in the Cayman Islands and NE Brazil

This paper explores the relationship between disaster risk reduction and long-term adaptive capacity building in two climate vulnerable areas—the Cayman Islands in the Caribbean and Ceará, in NE Brazil. Drawing on past applications of the disaster risk reduction framework, we identify four critical factors that have led to reductions in risk: flexible, learning-based, responsive governance; committed, reform-minded and politically active actors; disaster risk reduction integrated into other social and economic policy processes; and a long-term commitment to managing risk. We find that while the presence of these factors has reduced overall risk in both regions, in Ceará, disaster response as it is currently practiced, has fallen short of addressing the fundamental causes of vulnerability that leave those prone to hazards able to cope in the short term, yet enmeshed in poverty and at risk from the longer-term changes associated with climate change. Although calls for integration of disaster risk management with poverty eradication are not new, there has been insufficient attention paid in the literature on how to foster such integration. Based on the two case studies, we argue that the adoption of good governance mechanisms (such as stakeholder participation, access to knowledge, accountability and transparency) in disaster risk reduction policy may create the policy environment that is conducive to the kind of structural reform needed to build long-term adaptive capacity to climate-driven impacts. We conclude that without a synergistic two-tiered approach that includes both disaster risk reduction and structural reform, disaster risk reduction, in the face of climate changes, will prove to be an expensive and ineffective palliative treatment of changing risks

Implementation Action Plan for organic food and farming research

The Implementation Action Plan completes TP Organics’ trilogy of key documents of the Research Vision to 2025 (Niggli et al 2008) and the Strategic Research Agenda (Schmid et al 2009). The Implementation Action Plan addresses important areas for a successful implementation of the Strategic Research Agenda. It explores the strength of Europe’s organic sector on the world stage with about one quarter of the world’s organic agricultural land in 2008 and accounting for more than half of the global organic market. The aims and objectives of organic farming reflect a broad range of societal demands on the multiple roles of agriculture and food production of not only producing commodities but also ecosystem services. These are important for Europe’s economic success, the resilience of its farms and prosperity in its rural areas. The organic sector is a leading market for quality and authenticity: values at the heart of European food culture. Innovation is important across the EU economy, and no less so within the organic sector. The Implementation Action Plan devotes its third chapter to considering how innovation can be stimulated through organic food and farming research and, crucially, translated into changes in business and agricultural practice. TP Organics argues for a broad understanding of innovation that includes technology, know-how and social/organisational innovations. Accordingly, innovation can involve different actors throughout the food sector. Many examples illustrate innovations in the organic sector includign and beyond technology. The various restrictions imposed by organic standards have driven change and turned organic farms and food businesses into creative living laboratories for smart and green innovations and the sector will continue to generate new examples. The research topics proposed by TP Organics in the Strategic Research Agenda can drive innovation in areas as wide ranging as production practices for crops, technologies for livestock, food processing, quality management, on-farm renewable energy or insights into the effects of consumption of organic products on disease and wellbeing and life style of citizens. Importantly, many approaches developed within the sector are relevant and useful beyond the specific sector. The fourth chapter addresses knowledge management in organic agriculture, focusing on the further development of participatory research methods. Participatory (or trans-disciplinary) models recognise the worth and importance of different forms of knowledge and reduced boundaries between the generators and the users of knowledge, while respecting and benefitting from transparent division of tasks. The emphasis on joint creation and exchange of knowledge makes them valuable as part of a knowledge management toolkit as they have the capacity to enhance the translation of research outcomes into practical changes and lead to real-world progress. The Implementation Action Plan argues for the wider application of participatory methods in publicly-funded research and also proposes some criteria for evaluating participatory research, such as the involvement and satisfaction of stakeholders as well as real improvements in sustainability and delivery of public goods/services. European agriculture faces specific challenges but at the same time Europe has a unique potential for the development of agro-ecology based solutions that must be supported through well focused research. TP Organics believes that the most effective approaches in agriculture and food research will be systems-based, multi- and trans-disciplinary, and that in the development of research priorities, the interconnections between biodiversity, dietary diversity, functional diversity and health must be taken into account. Chapter five of the action plan identifies six themes which could be used to organise research and innovation activities in agriculture under Europe’s 8th Framework Programme on Research Cooperation: • Eco-functional intensification – A new area of agricultural research which aims to harness beneficial activities of the ecosystem to increase productivity in agriculture. • The economics of high output / low input farming Developing reliable economic and environmental assessments of new recycling, renewable-based and efficiency-boosting technologies for agriculture. • Health care schemes for livestock Shifting from therapeutics to livestock health care schemes based on good husbandry and disease prevention. • Resilience and “sustainagility” Dealing with a more rapidly changing environment by focusing on ‘adaptive capacity’ to help build resilience of farmers, farms and production methods. • From farm diversity to food diversity and health and wellbeing of citizens Building on existing initiatives to reconnect consumers and producers, use a ‘whole food chain’ approach to improve availability of natural and authentic foods. • Creating centres of innovation in farming communities A network of centres in Europe applying and developing trans-disciplinary and participatory scientific approaches to support innovation among farmers and SMEs and improving research capacities across Europe

Toward quantifying metrics for rail-system resilience: Identification and analysis of performance weak-resilience-signals

This paper aims to enhance tangibility of the resilience engineering concept by facilitating understanding and operationalization of weak-resilience-signals (WRS) in the rail sector. Within complex socio-technical systems, accidents can be seen as unwanted outcomes emerging from uncontrolled sources of entropy (functional resonance). Various theoretical models exist to determine the variability of system interactions, the resilience state, and the organization’s intrinsic abilities to reorganize and manage their functioning and adaptive capacity to cope with unexpected and unforeseen disruptions. However, operationalizing and measuring concrete and reliable manifestations of resilience and assessing their impact at a system level, has proven to be a challenge. A multi-method, ethnographic observation and resilience questionnaire, was used to determine resilience baseline conditions at an operational rail traffic control post. This paper describes the development, implementation and initial validation of WRSs identified and modelled around a ‘performance system boundary’. In addition, a WRS analysis function is introduced to interpret underlying factors of the performance WRSs and serves as a method to reveal potential sources of future resonance that could comprise system resilience. Results indicate that performance WRSs can successfully be implemented to accentuate relative deviations from resilience baseline conditions. A WRS analysis function can help to interpret these divergences, and could be used to reveal (creeping) change processes and unnoticed initiating events that facilitate emergence that degrades rail-system resilience. Establishing relevant change signals in advance can contribute to anticipation and awareness, enhance organizational learning and stimulate resilient courses of action and adaptive behavior that ensures rail operation reliability

Improving e-therapy for mood disorders among lesbians and gay men

Introduction This toolkit provides the first comprehensive set of guidelines for tailoring mood-disorder e-therapies to the needs of same-sex attracted people. It gives developers of e-therapies a set of practical recommendations for adjusting e-therapies to more effectively accommodate lesbians and gay men. These recommendations are supported by in-depth research that was designed specifically to inform this toolkit. Summaries of this research are provided in the toolkit and detailed findings are available in published research articles. This toolkit also provides information on the mental health-related challenges that are often faced by same-sex attracted people and links readers to key resources and organisations for further information. Checklists and other tools are included as aids for developers to assess the inclusiveness and relevance of e-therapies to lesbians and gay men. In short, this toolkit contains an extensive set of tools and explains why and how they could be implemented

Strategic Research Agenda for organic food and farming

The TP Organics Strategic Research Agenda (SRA) was finalised in December 2009. The purpose of the Strategic Research Agenda (SRA) is to enable research, development and knowledge transfer that will deliver relevant outcomes – results that will contribute to the improvement of the organic sector and other low external input systems. The document has been developed through a dynamic consultative process that ran from 2008 to 2009. It involved a wide range of stakeholders who enthusiastically joined the effort to define organic research priorities. From December 2008 to February; the expert groups elaborated the first draft. The consultative process involved the active participation of many different countries. Consultation involved researchers, advisors, members of inspection/certification bodies, as well as different users/beneficiaries of the research such as farmers, processors, market actors and members of civil society organisations throughout Europe and further afield in order to gather the research needs of the whole organic sector