Showing papers by "Erik Hollnagel published in 2017"

Resilience – the Challenge of the Unstable

Abstract: For Resilience Engineering, 'failure' is the result of the adaptations necessary to cope with the complexity of the real world, rather than a breakdown or malfunction. The performance of individuals and organizations must continually adjust to current conditions and, because resources and time are finite, such adjustments are always approximate. This definitive new book explores this groundbreaking new development in safety and risk management, where 'success' is based on the ability of organizations, groups and individuals to anticipate the changing shape of risk before failures and harm occur. Featuring contributions from many of the worlds leading figures in the fields of human factors and safety, "Resilience Engineering" provides provocative insights into system safety as an aggregate of its various components, subsystems, software, organizations, human behaviours, and the way in which they interact. The book provides an introduction to Resilience Engineering of systems, covering both the theoretical and practical aspects. It is written for those responsible for system safety on managerial or operational levels alike, including safety managers and engineers (line and maintenance), security experts, risk and safety consultants, human factors professionals and accident investigators.

Prologue: Resilience Engineering Concepts

Abstract: For Resilience Engineering, 'failure' is the result of the adaptations necessary to cope with the complexity of the real world, rather than a breakdown or malfunction The performance of individual

Safety-II in Practice: Developing the Resilience Potentials

Abstract: Safety-I is defined as the freedom from unacceptable harm. The purpose of traditional safety management is therefore to find ways to ensure this ‘freedom’. But as socio-technical systems steadily have become larger and less tractable, this has become harder to do. Resilience engineering pointed out from the very beginning that resilient performance - an organisation’s ability to function as required under expected and unexpected conditions alike – required more than the prevention of incidents and accidents. This developed into a new interpretation of safety (Safety-II) and consequently a new form of safety management. Safety-II changes safety management from protective safety and a focus on how things can go wrong, to productive safety and a focus on how things can and do go well. For Safety-II, the aim is not just the elimination of hazards and the prevention of failures and malfunctions but also how best to develop an organisation’s potentials for resilient performance – the way it responds, monitors, learns, and anticipates. That requires models and methods that go beyond the Safety-I toolbox. This book introduces a comprehensive approach for the management of Safety-II, called the Resilience Assessment Grid (RAG). It explains the principles of the RAG and how it can be used to develop the resilience potentials. The RAG provides four sets of diagnostic and formative questions that can be tailored to any organisation. The questions are based on the principles of resilience engineering and backed by practical experience from several domains. Safety-II in Practice is for both the safety professional and academic reader. For the professional, it presents a workable method (RAG) for the management of Safety-II, with a proven track record. For academic and student readers, the book is a concise and practical presentation of resilience engineering.

Epilogue: RAG – The Resilience Analysis Grid

Abstract: Resilience is defined as the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions. Since resilience refers to something a system does (a capability or a process) rather than to something the system has (a product), it cannot be measured by counting specific outcomes such as accidents or incidents. This chapter describes an approach to measure the resilience of a system that focuses on the four main abilities that together constitute resilience: the ability to respond, the ability to monitor, the ability to anticipate and the ability to learn. These abilities can be assessed by means of a number of questions and the answers can be represented by an easily comprehensible graphical form. This can be used to compare consecutive measurements, and thereby as a way to support the management of a system’s resilience.

Learning How to Create Resilience in Business Systems

Abstract: For Resilience Engineering, 'failure' is the result of the adaptations necessary to cope with the complexity of the real world, rather than a breakdown or malfunction. The performance of individuals and organizations must continually adjust to current conditions and, because resources and time are finite, such adjustments are always approximate. This definitive new book explores this groundbreaking new development in safety and risk management, where 'success' is based on the ability of organizations, groups and individuals to anticipate the changing shape of risk before failures and harm occur. Featuring contributions from many of the worlds leading figures in the fields of human factors and safety, "Resilience Engineering" provides provocative insights into system safety as an aggregate of its various components, subsystems, software, organizations, human behaviours, and the way in which they interact. The book provides an introduction to Resilience Engineering of systems, covering both the theoretical and practical aspects. It is written for those responsible for system safety on managerial or operational levels alike, including safety managers and engineers (line and maintenance), security experts, risk and safety consultants, human factors professionals and accident investigators.

Predictors of the effectiveness of accreditation on hospital performance: A nationwide stepped-wedge study

Abstract: Objective To identify predictors of the effectiveness of hospital accreditation on process performance measures. Design A multi-level, longitudinal, stepped-wedge, nationwide study. Participants All patients admitted for acute stroke, heart failure, ulcers, diabetes, breast cancer and lung cancer at Danish hospitals. Intervention The Danish Healthcare Quality Programme that was designed to create a framework for continuous quality improvement. Main outcome measure(s) Changes in week-by-week trends of hospitals' process performance measures during the study period of 269 weeks prior to, during and post-accreditations. Process performance measures were based on 43 different processes of care obtained from national clinical quality registries. Analyses were stratified according to condition, type of care (i.e. treatment, diagnostics, secondary prevention and patient monitoring) and hospital characteristics (i.e. university affiliation, location, size, experience with accreditation and accreditation compliance). Results A total of 1 624 518 processes of care were included. The impact of accreditation differed across the conditions. During accreditation, heart failure and breast cancer showed less improvement than other disease areas. Across all conditions, diagnostic processes improved less rapidly than other types of processes. However, after stratifying the data by hospital characteristics, process performance measures improved more uniformly. In respect of the measures that had an unsatisfactory level of quality, the processes related to diabetes, diagnostics and patient monitoring all responded to accreditation and showed an increased improvement during the preparatory work. Conclusion Hospital characteristics were not found to be predictors for the effects of accreditation, whereas conditions and types of care to some extent predicted the effectiveness.

Compliance with accreditation and recommended hospital care—a Danish nationwide population-based study

Abstract: Objective To examine the association between compliance with accreditation and recommended hospital care. Design A Danish nationwide population-based follow-up study based on data from six national, clinical quality registries between November 2009 and December 2012. Setting Public, non-psychiatric Danish hospitals. Participants Patients with acute stroke, chronic obstructive pulmonary disease, diabetes, heart failure, hip fracture and bleeding/perforated ulcers. Interventions All hospitals were accredited by the first version of The Danish Healthcare Quality Programme. Compliance with accreditation was defined by level of accreditation awarded the hospital after an announced onsite survey; hence, hospitals were either fully (n = 11) or partially accredited (n = 20). Main Outcome Measures Recommended hospital care included 48 process performance measures reflecting recommendations from clinical guidelines. We assessed recommended hospital care as fulfilment of the measures individually and as an all-or-none composite score. Results In total 449 248 processes of care were included corresponding to 68 780 patient pathways. Patients at fully accredited hospitals had a significantly higher probability of receiving care according to clinical guideline recommendations than patients at partially accredited hospitals across conditions (individual measure: adjusted odds ratio (OR) = 1.20, 95% CI: 1.01-1.43, all-or-none: adjusted OR = 1.27, 95% CI: 1.02-1.58). For five of the six included conditions there were an association; the pattern appeared particular strong among patients with acute stroke and hip fracture (all-or-none; acute stroke: adjusted OR = 1.39, 95% CI: 1.05-1.83, hip fracture: adjusted OR = 1.57, 95% CI: 1.00-2.49). Conclusion High compliance with accreditation standards was associated with a higher level of evidence-based hospital care in Danish hospitals.

Proposing leading indicators for blood sampling: application of a method based on the principles of resilient healthcare

Abstract: In recent years, healthcare has put a growing attention to the investigation of successful processes as a supplement to analyzing and investigating unwanted processes, like adverse events and near misses. This new perspective paves the way for developing methods and tools for investigating and understanding how processes function, and how variability can contribute to both success and failure. In the light of this, we have developed a method applicable for identifying leading indicators for successful outcomes of complex healthcare processes. The method, which is termed leading indicator identification method (LIIM) was inspired from similar methods applied in high-risk industries. To demonstrate the usefulness of the method we have conducted a case study with the aim of identifying leading indicators for blood sampling among patients in a Biomedical Department within a Danish hospital. The method builds on and uses steps from the functional resonance analysis method (FRAM). FRAM was developed to analyze how work is performed on a daily basis, in complex systems and can be used prospectively to monitor, manage and control such systems. The contribution of the work is to present the LIIM along with four leading indicators that are important to consider in the planning, management and monitoring of the blood sampling process.

States of Resilience

Abstract: For Resilience Engineering, 'failure' is the result of the adaptations necessary to cope with the complexity of the real world, rather than a breakdown or malfunction. The performance of individuals and organizations must continually adjust to current conditions and, because resources and time are finite, such adjustments are always approximate. This definitive new book explores this groundbreaking new development in safety and risk management, where 'success' is based on the ability of organizations, groups and individuals to anticipate the changing shape of risk before failures and harm occur. Featuring contributions from many of the worlds leading figures in the fields of human factors and safety, "Resilience Engineering" provides provocative insights into system safety as an aggregate of its various components, subsystems, software, organizations, human behaviours, and the way in which they interact. The book provides an introduction to Resilience Engineering of systems, covering both the theoretical and practical aspects. It is written for those responsible for system safety on managerial or operational levels alike, including safety managers and engineers (line and maintenance), security experts, risk and safety consultants, human factors professionals and accident investigators.

Dual leadership in a hospital practice

Abstract: Purpose Despite the practice of dual leadership in many organizations, there is relatively little research on the topic. Dual leadership means two leaders share the leadership task and are held jointly accountable for the results of the unit. To better understand how dual leadership works, this study aims to analyse three different dual leadership pairs at a Danish hospital. Furthermore, this study develops a tool to characterize dual leadership teams from each other. Design/methodology/approach This is a qualitative study using semi-structured interviews. Six leaders were interviewed to clarify how dual leadership works in a hospital context. All interviews were transcribed and coded. During coding, focus was on the nine principles found in the literature and another principle was found by looking at the themes that were generic for all six interviews. Findings Results indicate that power balance, personal relations and decision processes are important factors for creating efficient dual leaderships. The study develops a categorizing tool to use for further research or for organizations, to describe and analyse dual leaderships. Originality/value The study describes dual leadership in the hospital context and develops a categorizing tool for being able to distinguish dual leadership teams from each other. It is important to reveal if there are any indicators that can be used for optimising dual leadership teams in the health-care sector and in other organisations.

Shouldn't Cars React as Drivers Expect?

Abstract: The objective of this project is to develop and test a multi-method empirical approach for predicting drivers- assessments of the level of acceptability of a warning issued in response to accidents ...

The Importance of Functional Interdependencies in Financial Services Systems

Abstract: The events of 2007–2009 in the global financial markets clearly illustrated the need of an improved understanding of how the global Financial Services System (FSS) functions. In particular, the crisis made it clear that national FSSs, or components of such systems such as individual banks, were highly dependent on the normal functioning of other components of the global FSS. The primary goal of this chapter is to introduce a functional framework that enables a proactive identification of risk associated with outcomes of actions – either planned or already taken. Key concepts from Resilience Engineering and functional modelling are leveraged to define the approach. The primary goal of the proposed framework is to identify key functional dependencies between an individual firm’s business functions and the functions that drive key behaviours of global financial markets. The rapid demise of the UK-based residential mortgage firm Northern Rock is used to illustrate the proposed framework.

Governance and Control of Financial Systems

Abstract: The recent financial crisis has made it paramount for the financial services industry to find new perspectives to look at their industry and, most importantly, to gain a better understanding of how the global financial system can be made less vulnerable and more resilient. The primary objective of this book is to illustrate how the safety science of Resilience Engineering can help to gain a better understanding of what the financial services system is and how to improve governance and control of financial services systems by leveraging some of its key concepts. Resilience is the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions. This definition is focused on the ability to function, rather than just to be impervious to failure, and thereby bridges the traditional conflict between productivity and safety. The core concept of the book is that the behaviour of the financial services system is the result of the tight couplings among the humans, organizations and technologies that are necessary to provide complex financial functions such as the transfer of economic resources. It is a consequence of this perspective that the risks associated with these systems cannot be understood without considering the nature of these tight couplings. Adopting this perspective, the book is designed to provide some answers to the following key questions about the financial crisis: - What actually happened? - Why and how did it happen? - Could something similar happen again? How can we see that in time and how can we control it? - How can sustainable recovery of the global financial system be established? How can its resilience be improved?