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Resilience and Reliability With the Patient in the Centre

Posted by Carolyn Canfield on Thursday October 24th, 2013

On the face of it, patient safety is all about the patient, isn’t it? I’d like to relate a patient’s view of safety within a system frame, building on Sydney Dekker’s challenges in his 2013 Lund University talk about ‘just culture’.

Resilience engineering and reliability of care would have this complex adaptive system of healthcare routinely, and vigorously, focus on securing patient safety. However, we observe -- and sometimes receive – healthcare that is hazardous. Moreover, patients and their families rarely play an active role in, or are even aware of, safety culture and vigilance. Looking across “best practice” strategies intended to strengthen safety, the patient often seems a bystander and a bit of an afterthought, if recognized at all.

Dekker proposes that resilience, or “forward-looking accountability” will thrive only where system participants feel reasonably secure that reports will be treated fairly and that those with power truly want to know about safety events. A resilient system makes learning and accountability compatible.

Arguably no one is more central to safety risk and lapses than the patient. And yet, as Dekker challenges: ‘Who gets the power to draw the line between acceptable risk and safety hazard? What versions of the story of harmful care are collected as evidence? Who writes the history?’ The power structures that frame the account will skew whatever counter measures might be advanced for safer care.

Limiting points of view grossly diminishes the available expertise for understanding and building elements of resilience. The patient as victim, as witness, is a unique expert in the experience of harm. How could the full complexity of care not encompass patient and family stories of the harm, however contradictory and overlapping the totality of accounts might be? The truth of the victim experience of harm trumps the medical precision of the account.

Without a champion within the system, patients may fear that openness will actually trigger harm. For the healthcare worker who becomes a system client, prior knowledge and experience with marginalized “problem” patients and family members may muzzle their own assertiveness, in spite of knowing that safety resides in free and trusting communication between patient and provider.

In the midst of this heritage of disengagement, patient and family centred culture is starting to impact progressive provider systems, thanks to the courage of early adopters. With this transformation comes a redefinition of healthcare quality according to patient preferences, and a massive, if gradual, power shift, affording an equally massive infusion of energy and imagination for new models for care provision. The patient and family are joining the healthcare team with knowledge and insight into what outcomes matter, what constitutes value and when it is achieved or failed. Can patient participation in defining and delivering on healthcare resilience be far behind?

Let’s apply Hollnagel’s framework to explore some directions for patient participation in resilience. (Hollnagel, Erik. 2010. How Resilient Is Your Organisation? An Introduction to the Resilience Analysis Grid (RAG). Sustainable Transformation: Building a Resilient Organization.)

The ability to respond: How ready is the organization to respond when something unexpected happens? Do healthcare workers learn from patients and family members if safety is secure, or harm has occurred? Do providers learn from patients and families what their safety needs are, and how to respond effectively either proactively for resilience, or reflexively following harm or risk of harm?

The ability to monitor: How well is the organization able to detect changes that may affect its operations? Can patients securely inform providers when they feel safe, or vulnerable to harm? How would providers learn if patients experience a change? Are confident and trusting patients considered and assessed as system objectives. Do confident and trusting patients also experience better clinical outcomes that maximize value for care delivered?

The ability to anticipate: How large an effort does the organization put into foreseeing what may happen in the future? Are citizen-patient advisors embedded in improvement processes, planning and evaluation? Are patient peer counselors distributed throughout care settings to support patients and families, observe care effectiveness, detect change and offer early warning for system stresses?

The ability to learn: How well does the organization use opportunities to learn from what happened in the past? Are patients and family members integrated into safety reviews and system resilience scanning? Do patients and family members provide feedback to providers on near miss, harmful incident impact and resolution outcomes? Are patients and family members encouraged to propose innovations and improvements for secure and trustworthy care experiences?

Having planted the seed of possibility for welcoming powerfully motivated patients to pursue resilience enthusiastically, I hope you will consider what accelerators and roadblocks lie ahead for including the patient at the centre of practice and structure for safer care. I look forward to exploring these ideas with you, and introducing the notion of reciprocal trust relationships to support reliability and sustainability in healthcare. Please join me for the November 7 teleconference using the link on this webpage for a spirited discussion! 


For further reading... 

Carrillo, Rosa Antonia. 2012. "Relationship-based safety: moving beyond culture & behavior". PROFESSIONAL SAFETY. Vol 57 (12) (December 2012)

Organizations depend on people to solve problems and innovate when unexpected events occur. To fully utilize this human capability, social interaction is a necessary part of the problem-solving process. The relationship-based change model framework encompasses these elements and represents a unique and distinct approach to managing change. The model incorporates the concepts and insights provided by CMT [Complexity Management Theory] and the past 50 years of organizational development experience. It focuses on establishing structures to ensure adaptive responses to change and the effective management of ambiguity. It encompasses strategies to build and maintain relationships, communication networks and processes, problem-solving and communication skills, and related competencies.

Dekker, Sidney, Bergström, Johan, Amer-Wåhlin, Isis, and Cilliers, Paul. 2013.Complicated, complex and compliant: Best practice in obstetrics. Cognition, Technology & Work. 15(2): 189-195.

Complex systems consist of numerous components or agents that are interrelated in all kinds of ways, and they are open systems. They keep changing in interaction with their environment, and their boundaries are difficult to determine. It can be hard to find out (or it is ultimately arbitrary) where the system ends and the environment begins.... Success in a complex system flows not from having it follow one best method—but from a diversity of responses that allow it to cope with a changing environment…. Theoretically, success and resilience in complex systems derives not from compliance, but from diversity.

Francis, Royce, and Behailu Bekera. 2014. "A metric and frameworks for resilience analysis of engineered and infrastructure systems". Reliability Engineering & System Safety. 121 (4): 90-103.

The idea of design for ecological versus engineered resilience in socio-technical systems is an emerging concept that advocates the design of engineered systems based on the ecological principles of diversity, adaptability, interconnectedness, mutual evolution, and flexibility. Investigators developing these ideas are motivated by the idea that irrevocable uncertainty leaves risk-optimized systems vulnerable to catastrophic failures attributable to unknowable or unforeseen events. As a result, efforts in design should be allocated to increase emphasis on “safe-fail” rather than “fail-safe” provisions. In the present authors'''' opinion, this point of view is compelling.

Gittell, Jody Hoffer. 2009. High performance healthcare: using the power of relationships to achieve quality, efficiency and resilience. New York: McGraw-Hill.

A proactive, cross-functional approach to performance measurement helps to create a sense of shared goals, shared knowledge, and mutual respect among care providers who are working together to provide care to patients. These positive relationships support frequent, timely, problem-solving communication, helping to further develop positive relationships. An approach to performance measurement that is both proactive and cross-functional helps to develop high levels of relational coordination, ultimately improving the quality and efficiency of patient care.

Hofmeyer A, and PB Marck. 2008. "Building social capital in healthcare organizations: thinking ecologically for safer care". Nursing Outlook. 56 (4).

With this primary goal of creating safer places for patients and practitioners in view, leaders can focus their attention on assessing and strengthening 5 dimensions of social capital within their organizations: (1) groups and networks, (2) trust and solidarity, (3) collective action and cooperation, (4) information and communication, and (5) social cohesion and inclusion…. For each of the 5 dimensions of social capital, we offer examples of concrete initiatives that leaders can direct or support to foster social capital in meaningful ways. Social capital is manifested in networks and ties with bonding (between individuals within groups), bridging (between groups), and linking (others with differential power status) capacity and relational/cognitive norms such as trust, cooperation, reciprocity, cohesion and inclusion.

Iedema R. 2011. "Creating safety by strengthening clinicians'''' capacity for reflexivity". BMJ Quality and Safety. 20 (SUPPL. 1): i83-i86.

Safety does not flow automatically from acting out a guideline or standard. Safety has to be worked at from moment to moment. This in situ creation of safety has been talked about in the literature in different ways: as ‘error wisdom,‘ resilience and mindfulness. Error wisdom manifests when clinicians respond quickly, flexibly and sensitively to problem situations, colleagues in trouble and patients susceptible to risk... Resilience comes to the fore when frontline staff and patients adapt what they do to avert impending failures…. Mindfulness happens when clinicians and patients become able to think and act with one another and, at times, for one another.

Langley A, and JL Denis. 2011. "Beyond evidence: the micropolitics of improvement". BMJ Quality & Safety. 20 (SUPPL. 1): i43-i46.

Unfortunately, there is some truth to the idea that healthcare organisations sometimes seem to diffuse power among almost everyone, except the people for whom they exist—the patients needing care.


Carrillo, Rosa Antonia. 2012. "Relationship-based safety: moving beyond culture & behavior". PROFESSIONAL SAFETY. Vol 57 (12) (December 2012)

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Carolyn Canfield collaborates as a citizen-patient with healthcare teams, patients and families, provider organizations, researchers and educators to embed the patient voice in improvement processes. She champions patient expertise as the driver for creativity and sustainability in system transformation, aiming to fulfill the care excellence aspirations of both clients and practitioners. Carolyn’s energetic full-time commitment arises from premature widowhood in 2008 following preventable harm. As keynote speaker, project presenter, panelist and instructor, Carolyn has been honoured by invitations to address committed professionals at the BMJ/IHI International Forum 2014; the Royal College of Physicians and Surgeons of Canada; Fraser Health Authority’s Ethics Conference and clinical workshops; the BC Surgical Quality Action Network; the BC Provincial Infection Control Network; the Perioperative Nurses Association of BC; the Canadian Patient Safety Officer Course; BC’s Quality Academy; the University of British Columbia’s School for Population and Public Health; the Faculty of Health Sciences at Simon Fraser University.



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