Resilience in Healthcare

The following post is by Guest author, Natalie Lin, University of Michigan MHSA Candidate & MedStar Health Quality & Safety Intern, Summer 2013. Natalie recently attended “Ideas to Innovation: Stimulating Collaborations in the Application of Resilience Engineering to Healthcare”, and she shares her reflections from the meeting.

Resilience ConferenceOne of the main concepts that has been drilled into my head in school, at MedStar Health, and at the recent Resilience Engineering conference co-hosted by the University-Industry Demonstration Partnership and MedStar, is that we don’t have a safety problem in health care, we have a systems problem. Systems fail, and disaster happens. Traditionally in health care, this is where the finger-pointing begins, because we think doctors are supposed to be perfect, and because we need someone to blame for the mistakes–mistakes that have hurt people. Slowly but surely, we have realized that pointing fingers isn’t going to help.

During this conference, we discussed the idea of resilience–what it is, and where we can find it in health care.  In health care, we’ve only just begun documenting and studying the accidents and mistakes that happen. We then implement checklists, guidelines, and barriers to avoid making the same mistake again. I thought this was a huge step forward. Apparently, this is the idea of “Safety I”, where the assumption is that the system is well designed and well understood. Given that health care is very complex and that the system is neither well designed nor well understood, I learned that perhaps Safety I is not the exact model we should be following.

Safety II, an alternate view, assumes that we have an unsafe system. What if, instead of constraining associates with checklists and guidelines, people could learn to adapt to conditions to prevent accidents? Safety II describes safety as an activity, and studying normal work to manage, not eliminate, the unexpected, because the absence of events does not equal the presence of safety. Of course, in order to do so, we have to be transparent and be able to understand the flaws in our system so that we are able to respond, monitor, learn, and anticipate  the risks before failure and harm can occur. The current literature suggests that we move from a Safety I approach to a Safety II approach, but what I struggle with is–are the two really mutually exclusive?

The concept of resilience in health care is still blurry for me. In the brief exposure that I’ve had to Lean, one of the things that I’ve learned was that we create “workarounds” to problems that arise. Lean teaches us to identify, address, and correct the root cause of the problem in order to eliminate workarounds, thereby making processes more efficient and safe. For example, if we place drugs with similar names right next to each other on the same shelf, how can we expect the pharmacists to be able to pick out the right drug and the right dosage, every single time, when this set up is just a disaster waiting to happen? With Lean thinking, we might come up with a solution to label the drugs more clearly or color code the bins. However, resilience engineering prompts us to study “how they do that”, how the pharmacist is able to pick out the right drug, almost all of the time. It’s a miracle that mistakes aren’t being made every single time! And that is resilience. I cannot say that I am completely sold on this idea yet, but I am trying to process it and re-work my thinking. In the meantime, where else can we find resilience in health care?

After all this talk on resilience and brittleness, Sorrel King’s point is what hit home for me. She said, it all boils down to inspiring the caregivers. Caregivers, who are the ones in daily contact with patients and families, need to be inspired and motivated. They are the ones who “do the work”. Along with being inspired and motivated, we need to provide a supportive culture, where they can feel comfortable and truly work as a team, and will want to work that much harder, knowing that their efforts will save the little girl down the hall. Health care might be extremely complex, but we can’t lose sight of the simplicity of it all–the patient.

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