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

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 (IV) 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 IV 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 Health Care 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 IV 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 IV 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 IV insulin infusions

A detailed analysis of ‘Work As Imagined’ in the use of intravenous insulin infusions in a hospital: a hierarchical task analysis

Objective: Variable rate intravenous insulin infusion (VRIII) is a high-risk medication that has a potential to cause significant patient harm if used in error. Complex preparation of VRIII in clinical areas and the need for frequent monitoring and adjustment increase the complexity of using VRIII. An emerging approach, called Resilient Health Care, proposes understanding complexity of work by exploring how work is assumed to be done and compare it with everyday work. This study aimed to explore how VRIIIs are perceived to be used by healthcare practitioners, focusing on one aspect of RHC: understanding how work is assumed to be done by using a method called Hierarchical Task Analysis (HTA). Design: A qualitative study using document analysis and focus groups. Setting: A Vascular Surgery Unit in a UK tertiary, acute National Health Service (NHS) teaching hospital. Participants: Various stakeholders/users in different professional roles involved in the process of using VRIIIs. Results: The HTA showed the complexity of using VRIII and highlighted more than 115 steps required to treat elevated blood glucose. The process of producing hospital-specific guidelines was iterative. Careful consideration was taken to coordinate the development and implementation of guidelines. Documents provided detailed clinical instructions related to the use of VRIII but practitioners selectively used them, often in deference to senior colleagues. Intentional adaptations e.g. proactively asking for a VRIII prescription occurred and were acknowledged as part of providing individualised patient care. Conclusion: Using VRIII to treat elevated blood glucose is a complex but necessary process mediated by a range of factors such as organisational influences. Adaptive strategies to mitigate errors were common and future research can build on insights from this study to develop a broader understanding of how VRIIIs are used and to understand how adaptations are made in relation to the use of VRIII

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, 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

Choosing and evaluating randomisation methods in clinical trials: a qualitative study

Background: There exist many different methods of allocating participants to treatment groups during a randomised controlled trial. Although there is research that explores trial characteristics that are associated with the choice of method, there is still a lot of variety in practice not explained. This study used qualitative methods to explore more deeply the motivations behind researchers’ choice of randomisation, and which features of the method they use to evaluate the performance of these methods. Methods: Data was collected from online focus groups with various stakeholders involved in the randomisation process. Focus groups were recorded and then transcribed verbatim. A thematic analysis was used to analyse the transcripts. Results: Twenty-five participants from twenty clinical trials units across the UK were recruited to take part in one of four focus groups. Four main themes were identified: how randomisation methods are selected; researchers’ opinions of the different methods; which features of the method are desirable and ways to measure method features. Most researchers agree that the randomisation method should be selected based on key trial characteristics; however, for many, a unit standard is in place. Opinions of methods were varied with some participants favouring stratified blocks and others favouring minimisation. This was generally due to researchers’ perception of the effect these methods had on balance and predictability. Generally, predictability was considered more important than balance as adjustments cannot be made for it; however, most researchers felt that the importance of these two methods was dependent on the design of the study. Balance is usually evaluated by tabulating variables by treatment arm and looking for perceived imbalances, predictability was generally considered much harder to measure, partly due to differing definitions. Conclusion: There is a wide variety in practice on how randomisation methods are selected and researcher’s opinions on methods. The difference in practice observed when looking at randomisation method selection can be explained by a difference in unit practice, and also by a difference in researchers prioritisation of balance and predictability. The findings of this study show a need for more guidance on randomisation method selection

Widening participation – recruitment methods in mental health randomised controlled trials: a qualitative study

Background: Barriers to mental health research participation are well documented including distrust of services and research; and stigma surrounding mental health. They can contribute to a lack of diversity amongst participants in mental health research, which threatens the generalisability of knowledge. Given the recent widespread use of the internet in medical research, this study aimed to explore the perspectives of key partners on the use of online (e.g. social media) and offline (e.g. in-person) recruitment as an approach to improving diversity in mental health randomised controlled trials (RCTs).Methods: Face-to-face and online interviews/focus groups with researchers working in mental health and Patient and Public Involvement partners in the United Kingdom. Recordings were transcribed and analysed using a combination of inductive and deductive thematic analysis.Results: Three focus groups and three interviews were conducted with a total N=23 participants. Four overarching themes were identified: (1) recruitment reach; (2) Demographic factors that affect selection of recruitment method; (3) safety of technology, and; (4) practical challenges. Five main factors were identified that affect the choice of recruitment method: age, complexity of mental health problem and stigma, cultural and ethnicity differences and digital divide. The use of online methods was considered more accessible to people who may feel stigmatised by their mental health condition and with a benefit of reaching a wider population. However, a common view amongst participants was that online methods require closer data monitoring for quality of responders, are not fully secure and less trustworthy compared to offline methods that enable participants to build relationships with health providers. Funding, staff time and experience, organisational support, and technical issues such as spam or phishing emails were highlighted as practical challenges facing online recruitment. All participants agreed that using a hybrid approach tailored to the population under study is paramount.Conclusions: This study highlighted the importance of offering a flexible and multifaceted recruitment approach by integrating online with offline methods to support inclusivity and widening participation in mental health research. The findings will be used to develop considerations for researchers designing RCTs to improve recruitment in mental health research

Understanding safety differently: developing a model of intravenous insulin infusion use in hospital inpatients

Introduction: Variable rate intravenous insulin infusions (VRIIIs) are very effective in managing hyperglycaemia in hospital inpatients when used correctly. However, if used incorrectly, they can cause harm or even death. Unlike traditional safety approaches that focus on ensuring adherence to predefined standards and identifying errors to prevent their recurrence, Resilient Health Care (RHC) shifts the focus to understanding variability in work, including both successes and failures. RHC achieves this by comparing Work as Imagined (WAI) (what people expect themselves and others to do) with Work as Done (WAD) (what people actually do) with the aim of realigning WAI with WAD in order to reflect reality. Aim: To develop a model of VRIII use in adult inpatients informed by the RHC framework. Methods: This mixed methods study was conducted in three phases at a Vascular Surgery Unit in a tertiary teaching hospital in England, UK. Phase I: Exploring WAI. Analysis of all documents related to VRIII use, and focus groups with users of VRIII. Documents and transcripts were analysed using inductive/deductive analysis. Phase II: Exploring WAD. Video Reflexive Ethnography methodology and quantitative data were used. The qualitative data were analysed using thematic analysis and the quantitative data were used to judge the outcomes of the observed tasks. Phase III: Model development. Two separate hierarchical task analyses (HTAs) were produced, one for each phase, to identify similarities and differences and to inform the development of the model of VRIII use. Results: WAI was perceived as a complex process that involved iterative tasks of producing hospital-specific guidelines and a multi-pronged approach to ensuring implementation of and adherence to guidelines. WAD was accomplished by using standardised practices (adhering to VRIII guidelines) and context-dependent adaptations (assigning blood glucose monitoring to other colleagues during busy shifts). Reflexive meetings revealed that a lack of knowledge in the selection of intravenous fluids and monitoring of blood glucose tasks was the main challenge faced while using VRIII. Suggestions from healthcare practitioners designed to overcome this challenge focused mainly on the need for face-to-face, VRIII-focused training that is tailored to their need. The comparison between WAI and WAD HTAs highlighted that most of the tasks in both HTAs were mostly aligned. The comparison also assisted in developing a model for the use of VRIII. The model showed that standardisation (WAI) and flexibility (context�dependent adaptations) must complement each other to ensure the delivery of patient care while using VRIII. The model also highlighted two key points to be considered when monitoring and continuously reviewing everyday clinical work and its resultant outcomes: 1) Understanding the permanence status of adaptations is a crucial step in differentiating between work that has long-term and short-term success. 2) Using monitoring tools such as checklists, clinical audits and VRE, corresponding to the type of task being performed is fundamental in reviewing everyday work and designing and implementing effective interventions that help in improving patient care while using VRIIIs. Conclusion: This research explored safety and complexity in the use of VRIIIs by integrating innovative methodologies inspired by the RHC construct of comparing WAI with WAD and by the VRE principles of exnovation, care, reflexivity and collaboration. The methods employed and findings of this thesis could help researchers as well as healthcare practitioners to better understand the use of VRIIIs in situ and move beyond describing concepts to providing practical recommendations, based on practical data obtained from a Vascular Surgery Unit, for improving safety and patient care delivery while using VRIII

Navigating complexity of the medication management system within the home setting - A Functional Resonance Analysis Method (FRAM) analysis of people with dementia and their carers’ experiences.

Background: There is a strong imperative to support people with dementia to live independently in their homes for as long as possible. A starting point is to understand how they manage medications on a daily basis. Aim: To understand how people with dementia and their informal carers manage medications within the home setting to inform the identification of opportunities to improve medication management. Methods: A qualitative study using the Functional Resonance Analysis Method (FRAM). Interview data with people with dementia and informal carers were analysed to: 1) Identify and describe key functions, 2) Identify and describe variability in performing key functions, and its potential consequences, and 3) Map performance variability to Resilient Healthcare capacities. Results and discussion: A FRAM model was developed and consisted of 14 interdependent key functions. The interdependent nature of functions, and the different nature and sources of variability in how each key function was performed highlighted the level of complexity of the medication management system within the home setting. The medication system was managed almost entirely by the person with dementia and/or their informal carers. This shows the lack of system-level controls to support the safe functioning of the medication management system in the home setting. Conclusion: Future work will develop a comprehensive FRAM model that includes the perspectives of health and social care professionals and those from the third sectors to underpin the development of a range of system recommendations to strengthen resilience in the medication management system within the home setting

Modelling the use of variable rate intravenous insulin infusions in hospitals by comparing Work as Done with Work as Imagined

Background: Variable rate intravenous insulin infusions (VRIIIs) are widely used to treat elevated blood glucose (BG) in adult inpatients who are severely ill and/or will miss more than one meal. VRIIIs can cause serious harm to the patient if used incorrectly. Recent safety initiatives have embraced the Resilient Health Care (RHC) approach to safety by understanding how VRIIIs are expected to be used (Work as Imagined, ‘WAI’) and how it is actually used in everyday clinical care (Work as Done, ‘WAD’). Objectives: To systematically compare WAI and WAD and analyse adaptations used in situ to develop a model explaining VRIII use. Methods: A qualitative observational study video-recording healthcare practitioners using VRIII. The video data were transcribed and inductively coded to develop a hierarchical task analysis (HTA) to represent WAD. This HTA was compared with a HTA previously developed to represent WAI. The comparison output was used to develop a model of VRIII use. Results: While many of the tasks in the WAD HTA were aligned with the tasks presented in the WAI HTA, some important ones did not. When misalignment was observed, permanent adaptations (e.g. signing as a witness for a changed VRIII’s rate without independently verifying whether the new rate was appropriate) and temporary workarounds (e.g. not administering long-acting insulin analogues although the long-acting insulin prescription was not suspended) were the most frequently observed adaptations. The comparison between WAI and WAD assisted in developing a model of VRIII use. The model shed light on strategies used to imagine everyday work (e.g. incident reports, VRIII guidelines), how everyday work was accomplished (e.g. context-dependent adaptations) and how these contributed to both successful and unsuccessful outcomes. Conclusions: This study provided in-depth understanding of the tasks required while using VRIIIs, and responses and adaptations needed to achieve safer care in a complex environment

Awareness of physicians and clinical pharmacists about ACC/AHA guidelines for dyslipidemia management: A cross sectional study

Introduction: Cardiovascular diseases (CVDs) are one of the leading causes of morbidity and mortality worldwide. Although genetics could contribute to the incidence of CVD, they are mostly acquired conditions. Management of precipitating factors such as hyperlipidemia can prevent CVD. Therefore, clinical guidelines have been used as a tool to improve patient outcomes and minimize practice variation. Objective: The objective of this study was to assess health-care providers’ (physicians and clinical pharmacists) awareness about the latest edition of the American College of Cardiology/American Heart Association (ACC/AHA) guidelines of dyslipidemia management. Materials and Methods: To meet the study objective, a self-administered questionnaire was designed based on the recommendations of the latest edition of the ACC/AHA guidelines for dyslipidemia management. After validation, the questionnaire was distributed to physicians and clinical pharmacists in Al-Ahsa province of Saudi Arabia. Results: Validation of the questionnaire was carried on 10 participants (Cronbach’s alpha = 0.816). Seventy-seven participants completed the questionnaire (acceptance rate = 51.33%). The majority of participants knew about the release of the ACC/AHA 2013 guidelines for dyslipidemia (77% of the physicians and 48% of the clinical pharmacist). Inadequate knowledge of the major changes in the dyslipidemia management was observed in both study groups with no significant difference between them (the median score for physicians and pharmacists was 4 out of 10 with a range of 1–9, Z = −0.15, P = 0.88).Conclusion: Inadequate level of knowledge about practice-changing recommendations of the recent ACC/AHA guidelines for dyslipidemia management was observed among the study participants. This level of knowledge could result in clinical malpractice and worsen management outcomes. Thus, efforts should be in place to raise awareness about the evidence-based management of dyslipidemia and monitor compliance to guidelines and their implementation outcomes