Understanding patient safety performance and educational needs using the ‘Safety-II’ approach for complex systems

Participation in projects to improve patient safety is a key component of general practice (GP) specialty training, appraisal and revalidation. Patient safety training priorities for GPs at all career stages are described in the Royal College of General Practitioners’ curriculum. Current methods that are taught and employed to improve safety often use a ‘find-and-fix’ approach to identify components of a system (including humans) where performance could be improved. However, the complex interactions and inter-dependence between components in healthcare systems mean that cause and effect are not always linked in a predictable manner. The Safety-II approach has been proposed as a new way to understand how safety is achieved in complex systems that may improve quality and safety initiatives and enhance GP and trainee curriculum coverage. Safety-II aims to maximise the number of events with a successful outcome by exploring everyday work. Work-as-done often differs from work-as-imagined in protocols and guidelines and various ways to achieve success, dependent on work conditions, may be possible. Traditional approaches to improve the quality and safety of care often aim to constrain variability but understanding and managing variability may be a more beneficial approach. The application of a Safety-II approach to incident investigation, quality improvement projects, prospective analysis of risk in systems and performance indicators may offer improved insight into system performance leading to more effective change. The way forward may be to combine the Safety-II approach with ‘traditional’ methods to enhance patient safety training, outcomes and curriculum coverage

The COVID-19 pandemic: resilient organisational response to a low-chance, high-impact event

The global healthcare sector is currently in the midst of the COVID-19 pandemic, a ‘low-chance, high-impact’ event which will require healthcare systems, and the organisations within them, to maintain organisational resilience in order to respond effectively. However, contrary to the instinctive reaction to tighten control, the quality of response depends on healthcare systems’ capacity to loosen control and, subsequently, enhance improvisation. Three factors critical to enhancing an organisation’s capacity for improvisation are highlighted; increasing autonomy, maintaining structure and creating a shared understanding. By drawing on the case of Christchurch Hospital’s response to a major earthquake, this paper demonstrates the vital role that improvisation can play within a clinical setting, when responding to a low-chance, high-impact event. This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained

Questioning, exploring, narrating and playing in the control room to maintain system safety

Systems whose design is primarily aimed at ensuring efficient, effective and safe working, such as control rooms, have traditionally been evaluated in terms of criteria that correspond directly to those values: functional correctness, time to complete tasks, etc. This paper reports on a study of control room working that identified other factors that contributed directly to overall system safety. These factors included the ability of staff to manage uncertainty, to learn in an exploratory way, to reflect on their actions, and to engage in problem-solving that has many of the hallmarks of playing puzzles which, in turn, supports exploratory learning. These factors, while currently difficult to measure or explicitly design for, must be recognized and valued in design

Sandy Regional Assembly Recovery Agenda

On January 26, 2013, nearly 200 participants representing over 40 community, environmental justice, labor and civic groups from across New York City, New Jersey and Long Island -- from the neighborhoods most impacted by Superstorm Sandy, and most vulnerable to future storm surges convened the Sandy Regional Assembly to strategize how government officials should implement a Sandy rebuilding program.In April 2013, these groups presented their Sandy Regional Assembly Recovery Agenda -- the first regional grassroots Sandy rebuilding and resiliency plan. The Recovery Agenda was a mix of suggested capital projects and policy recommendations, designed to advance 3 goals:Integrate regional rebuilding efforts with local resiliency priorities;Strengthen vulnerable communities & reduce public health threats, andExpand community-based climate change planning, disaster preparedness & response

Learning or leaving? An international qualitative study of factors affecting the resilience of female family doctors

Background: Many countries have insufficient numbers of family doctors, and more females than males leave the workforce at a younger age or have difficulty sustaining careers. Understanding the differing attitudes, pressures, and perceptions between genders toward their medical occupation is important to minimise workforce attrition. Aim: To explore factors influencing the resilience of female family doctors during lifecycle transitions. Design & setting: International qualitative study with female family doctors from all world regions. Method: Twenty semi-structured online Skype interviews, followed by three focus groups to develop recommendations. Data were transcribed and analysed using applied framework analysis. Results: Interview participants described a complex interface between competing demands, expectations of their gender, and internalised expectations of themselves. Systemic barriers, such as lack of flexible working, excessive workload, and the cumulative impacts of unrealistic expectations impaired the ability to fully contribute in the workplace. At the individual level, resilience related to: the ability to make choices; previous experiences that had encouraged self-confidence; effective engagement to obtain support; and the ability to handle negative experiences. External support, such as strong personal networks, and an adaptive work setting and organisation or system maximised interviewees’ professional contributions. Conclusion: On an international scale, female family doctors experience similar pressures from competing demands during lifecycle transitions; some of which relate to expectations of the female's ’role’ in society, particularly around the additional personal pressures of caring commitments. Such situations could be predicted, planned for, and mitigated with explicit support mechanisms and availability of workplace choices. Healthcare organisations and systems around the world should recognise this need and implement recommendations to help reduce workforce losses. These findings are likely to be of interest to all health professional staff of any gender

Crafting A Human Resource Strategy To Foster Organizational Agility: A Case Study

A decade ago, the CEO of Albert Einstein Healthcare Network (AEHN), anticipating a tumultuous and largely unpredictable period in its industry, undertook to convert this organization from one that was basically stable and complacent to one that was agile, “nimble, and change-hardy”. This case study briefly addresses AEHN’s approaches to business strategy and organization design, but focuses primarily on the human resource strategy that emerged over time to foster the successful attainment of organizational agility. Although exploratory, the study suggests a number of lessons for those who are, or will be, studying or trying to create and sustain this promising new organizational paradigm

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