Showing papers by "Erik Hollnagel published in 2015"

Resilient health care: turning patient safety on its head.

Abstract: The current approach to patient safety, labelled Safety I, is predicated on a 'find and fix' model. It identifies things going wrong, after the event, and aims to stamp them out, in order to ensure that the number of errors is as low as possible. Healthcare is much more complex than such a linear model suggests. We need to switch the focus to what we have come to call Safety II: a concerted effort to enable things to go right more often. The key is to appreciate that healthcare is resilient to a large extent, and everyday performance succeeds much more often than it fails. Clinicians constantly adjust what they do to match the conditions. Facilitating work flexibility, and actively trying to increase the capacity of clinicians to deliver more care more effectively, is key to this new paradigm. At its heart, proactive safety management focuses on how everyday performance usually succeeds rather than on why it occasionally fails, and actively strives to improve the former rather than simply preventing the latter.

Perspectives on Quality Resilient health care: turning patient safety on its head †

Abstract: The current approach to patient safety, labelled Safety I, is predicated on a ‘find and fix’ model. It identifies things going wrong, after the event, and aims to stamp them out, in order to ensure that the number of errors is as low as possible. Healthcare is much more complex than such a linear model suggests. We need to switch the focus to what we have come to call Safety II: a concerted effort to enable things to go right more often. The key is to appreciate that healthcare is resilient to a largeextent, and everyday performancesucceedsmuchmore often thanit fails. Clinicians constantly adjust what they do to match the conditions. Facilitating work flexibility, and actively trying to increase the capacity of clinicians to deliver more care more effectively, is key to this new paradigm. At its heart, proactive safety management focuses on how everyday performance usually succeeds rather than on why it occasionally fails, and actively strives to improve the former rather than simply preventing the latter.

Where the rubber meets the road: using FRAM to align work-as-imagined with work-as-done when implementing clinical guidelines

Abstract: Uptake of guidelines in healthcare can be variable. A focus on behaviour change and other strategies to improve compliance, however, has not increased implementation success. The contribution of other factors such as clinical setting and practitioner workflow to guideline utilisation has recently been recognised. In particular, differences between work-as-imagined by those who write procedures, and work-as-done—or actually enacted—in the clinical environment, can render a guideline difficult or impossible for clinicians to follow. The Functional Resonance Analysis Method (FRAM) can be used to model workflow in the clinical setting. The aim of this study was to investigate whether FRAM can be used to identify process elements in a draft guideline that are likely to impede implementation by conflicting with current ways of working. Draft guidelines in two intensive care units (ICU), one in Australia and one in Denmark, were modelled and analysed using FRAM. The FRAM was used to guide collaborative discussion with healthcare professionals involved in writing and implementing the guidelines and to ensure that the final instructions were compatible with other processes used in the workplace. Processes that would have impeded implementation were discovered early, and the guidelines were modified to maintain compatibility with current work processes. Missing process elements were also identified, thereby, avoiding the confusion that would have ensued had the guideline been introduced as originally written. Using FRAM to reconcile differences between work-as-imagined and work-as-done when implementing a guideline can reduce the need for clinicians to adjust performance and create workarounds, which may be detrimental to both safety and quality, once the guideline is introduced.

Why is Work-as-Imagined Different from Work-as- Done?

Abstract: A recurring theme in most if not all the chapters of this book is the difference between how work is being thought of either before it takes place when it is being planned or after it has taken place when the consequences are being evaluated, and how work is actually carried out where and when it happens. The two terms commonly used to describe this difference are work-as-imagined (WAI) and work-as-done (WAD). The distinction has been in use for more than half a century and is derived from the francophone use of the terms tâche (task) and activite (activity) from the 1950s onwards. The main reference in the French ergonomics literature is Leplat and Hoc (1983). At the same time Hollnagel and Woods (1983) proposed a distinction between the system task description (work-as-imagined) and the cognitive tasks (work-as-done). The distinction between WAI and WAD also played a role in the early discussions about resilience engineering, for instance in the first symposium 2004 as documented by Dekker (2006).

The resilience of everyday clinical work

Abstract: Contents: Preface, Robert L. Wears, Erik Hollnagel and Jeffrey Braithwaite A lesson in resilience: the 2011 Stanley Cup riot, Garth S. Hunte Translating tensions into safe practices through dynamic trade-offs: the secret second handover, Mark A. Sujan, Peter Spurgeon and Matthew W. Cooke Workarounds in nursing practice in acute care: a case of a health care arms race?, Deborah Debono and Jeffrey Braithwaite The demands imposed by a health care reform on clinical work in transitional care of the elderly: a multi-faceted Janus, Kristin Laugaland and Karina Aase The Stockholm blizzard of 2012, Mirjam Ekstedt and Richard I. Cook Individual-collective trade-offs: implications for resilience, Robert L. Wears, Christiane C. Schubert and Garth S. Hunte Managing medicines management: organisational resilience in community pharmacies, Denham Phipps, Darren Ashcroft and Dianne Parker Blood transfusion with health information technology in emergency settings from a Safety-II perspective, Kazue Nakajima Exposing hidden aspects of resilience and brittleness in everyday clinical practice using network theories, Jeffrey Braithwaite and Jennifer Plumb Patient boarding in the emergency department as a symptom of complexity-induced risks, Robert J. Stephens, David D. Woods and Emily S. Patterson Looking for patterns in everyday clinical work, Erik Hollnagel Tempest in a teapot: standardisation and workarounds in everyday clinical work, Shawna J. Perry and Rollin J. Fairbanks ECW in complex adaptive systems, Rob Robson Revealing resilience through critical incident narratives: a way to move from Safety-I to Safety-II, Sam Sheps, Karen Cardiff, Elaine Pelletier and Rob Robson Patients as a source of resilience, Christiane C. Schubert, Robert L. Wears, Richard J. Holden and Garth S. Hunte Strategies to get resilience into everyday clinical work, Sheuwen Chuang and Robert L. Wears Mobilising resilience by monitoring the right things for the right people at the right time, Al Ross and Janet E. Anderson Why is work-as-imagined different from work-as-done?, Erik Hollnagel Bibliography Index.

Compliance with hospital accreditation and patient mortality: a Danish nationwide population-based study

Abstract: Objective To examine the association between compliance with hospital accreditation and 30-day mortality. Design A nationwide population-based, follow-up study with data from national, public registries. Setting Public, non-psychiatric Danish hospitals. Participants In-patients diagnosed with one of the 80 primary diagnoses. Intervention Accreditation by the first version of The Danish Healthcare Quality Programme for hospitals from 2010 to 2012. Compliance were assessed by surveyors on an on-site survey and awarded the hospital as a whole; fully ( n = 11) or partially accredited ( n = 20). A follow-up activity was requested for partially accredited hospitals; submitting additional documentation ( n = 11) or by having a return-visit ( n = 9). Main Outcome Measure(s) All-cause mortality within 30-days after admission. Multivariable logistic regression was used to compute odds ratios (ORs) for 30-day mortality adjusted for six confounding factors and for cluster effect at hospital level. Results A total of 276 980 in-patients were identified. Thirty-day mortality risk for in-patients at fully ( n = 76 518) and partially accredited hospitals ( n = 200 462) was 4.14% (95% confidence interval (CI):4.00–4.28) and 4.28% (95% CI: 4.20–4.37), respectively. In-patients at fully accredited hospitals had a lower risk of dying within 30-days after admission than in-patients at partially accredited hospitals (adjusted OR of 0.83; 95% CI: 0.72–0.96). A lower risk of 30-day mortality was observed among in-patients at partially accredited hospitals required to submit additional documentation compared with in-patients at partially accredited hospitals requiring a return-visit (adjusted OR 0.83; 95% CI: 0.67–1.02). Conclusion Admissions at fully accredited hospitals were associated with a lower 30-day mortality risk than admissions at partially accredited hospitals.

Accreditation and improvement in process quality of care: a nationwide study.

Abstract: Objective To examine whether performance measures improve more in accredited hospitals than in non-accredited hospital. Design and setting A historical follow-up study was performed using process of care data from all public Danish hospitals in order to examine the development over time in performance measures according to participation in accreditation programs. Participants All patients admitted for acute stroke, heart failure or ulcer at Danish hospitals. Intervention Hospital accreditation by either The Joint Commission International or The Health Quality Service. Measurements The primary outcome was a change in opportunity-based composite score and the secondary outcome was a change in all-or-none scores, both measures were based on the individual processes of care. These processes included seven processes related to stroke, six processes to heart failure, four to bleeding ulcer and four to perforated ulcer. Results A total of 27 273 patients were included. The overall opportunity-based composite score improved for both non-accredited and accredited hospitals (13.7% [95% CI 10.6; 16.8] and 9.9% [95% 5.4; 14.4], respectively), but the improvements were significantly higher for non-accredited hospitals (absolute difference: 3.8% [95% 0.8; 8.3]). No significant differences were found at disease level. The overall all-or-none score increased significantly for non-accredited hospitals, but not for accredited hospitals. The absolute difference between improvements in the all-or-none score at non-accredited and accredited hospitals was not significant (3.2% [95% −3.6:9.9]). Conclusions Participating in accreditation was not associated with larger improvement in performance measures for acute stroke, heart failure or ulcer.

Is compliance with hospital accreditation associated with length of stay and acute readmission? A Danish nationwide population-based study

Abstract: Objective To examine the association between compliance with hospital accreditation and length of stay (LOS) and acute readmission (AR). Design A nationwide population-based follow-up study from November 2009 to December 2012. Setting Public, non-psychiatric Danish hospitals. Participants In-patients admitted with one of 80 diagnoses. Intervention Accreditation by the first version of The Danish Healthcare Quality Programme. Using an on-site survey, surveyors assessed the level of compliance with the standards. The hospital was awarded either fully ( n = 11) or partially accredited ( n = 20). Main Outcome Measures LOS including transfers between hospitals and all-cause AR within 30 days after discharge. The Cox Proportional Hazard regression was used to compute hazard ratios (HRs) adjusted for potential confounding factors and cluster effect at hospital level. Results For analyses of LOS, 275 589 in-patients were included of whom 266 532 were discharged alive and included in the AR analyses. The mean LOS was 4.51 days (95% confidence interval (CI): 4.46–4.57) at fully and 4.54 days (95% CI: 4.50–4.57) at partially accredited hospitals, respectively. After adjusting for confounding factors, the adjusted HR for time to discharge was 1.07 (95% CI: 1.01–1.14). AR within 30 days after discharge was 13.70% (95% CI: 13.45–13.95) at fully and 12.72% (95% CI: 12.57–12.86) at partially accredited hospitals, respectively, corresponding to an adjusted HR of 1.01 (95% CI: 0.92–1.10). Conclusion Admissions at fully accredited hospitals were associated with a shorter LOS compared with admissions at partially accredited hospitals, although the difference was modest. No difference was observed in AR within 30 days after discharge.

Disaster Management, Control, and Resilience

Abstract: This chapter looks at disaster management as a form of safety management, using the perspective of resilience engineering. In safety management, control can be lost by not being ready to respond, by having too little time, by lacking knowledge of what is going on, or by lacking the necessary resources. To maintain control unsurprisingly requires the converse of these conditions. Resilience engineering looks at how systems can sustain required operations under both expected and unexpected conditions by adjusting its functioning prior to, during, or following changes, disturbances, and opportunities. To do so requires the abilities to respond to what happens, to monitor the situation, to learn from what has happened, and to anticipate what may happen. The same type of analysis can be applied to disaster management, to better understand how it succeeds.

Looking for patterns in everyday clinical work

Abstract: The study of Everyday Clinical Work (ECW) may seem puzzling for researchers and practitioners who are accustomed to the type of clinical research that dominates modern health care. The purpose of clinical research is to determine whether something – a new type of medication, a new device, a new diagnostic product or a new treatment regime intended for human use – is sufficiently safe and effective. Clinical research follows the tradition of empirical research and the scientific method honoured by Western science since Roger Bacon, where researchers propose hypotheses and design experimental studies to test the predictions derived from the hypotheses. Or they try at any rate to determine whether changes to one or more independent variables have predictable, or at least systematic, effects that can be measured by the dependent variables. The scientific method is intended to be as objective as possible in order to reduce subjective biases in either the collection of data or the interpretation of results.

Systemic Accidents from a Resilience Engineering Perspective

Abstract: In a historical way safety has been defined by its opposite, since its improvement has been measured by the reduction of safety-related events. In other words, safety has been measured by the ‘ lack of safety ’ . The European Technology Platform on Industrial Safety (2005) gives a good example of this view by stating that industrial safety performance will progress in a steady and measurable way reducing accident-related losses, occupational diseases and environmental incidents. Normal 0 21 false false false PT-BR X-NONE X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Tabela normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0cm 5.4pt 0cm 5.4pt; mso-para-margin-top:0cm; mso-para-margin-right:0cm; mso-para-margin-bottom:10.0pt; mso-para-margin-left:0cm; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Cambria","serif"; mso-ascii-font-family:Cambria; mso-ascii-theme-font:minor-latin; mso-hansi-font-family:Cambria; mso-hansi-theme-font:minor-latin; mso-ansi-language:NL; mso-fareast-language:JA;}