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Resiliency -- time for a conversation

Posted by Hugh McLeod, CEO Canadian Patient Safety Institute on Monday October 6th, 2014

The BLOG for the next Resilience Learning Network Teleconference was first published at as part of Hugh McLeod's Ghost Busting Series and is available at  Resiliency--time for a conversation

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November 5th, 2014
Resilience rides a Trojan Horse and encounters HIPPOs

How would you promote the Safety II idea with your colleagues?

Leaders may think that they are supposed to have the solutions, and there may be an inherent anxiety where any solution is better than none. Many healthcare leaders are “fixers” ,perfection driven ex-clinicians who have been deeply steeped in Tayloristic Management ideas. They may however be very ready to recognise (when asked) how important variation is to every day work.

Ideas at the intersections of disciplines are resisted :

Karim Lakani , a Harvard Professor in “Looking beyond the knowledge frontier” discusses the struggle to get original ideas off the ground. “ There is tremendous resistance to novel ideas” They found that research evaluators systematically give lower scores to highly novel research proposals:
CBC the Current Oct 27.2014

Resilience rides a Trojan Horse

I think that resilience thinking must be demonstrated by pragmatic examples vs. underdeveloped theories and can be used concurrently with the common Tayloristic methods such as LEAN, to demonstrate it’s rightful place. The Trojan Horse (wearing LEAN armour) may be successful by hiding resilience engineering principles (they are not completely incompatible concepts)

One approach I’ve had some success in is using the tool box example to meet people where they are . These ideas are : linear tools/ flexible tools and make a system diagnosis

1) Linear tools for linear problems : Eg: When problems of the organization of work flow are well described, predicable, visible and chronic such as ; managing work flow and clutter in an outpatient clinic, a mechanistic Lean approach may be quite useful to standardize that which should be standardized. This provides comfort to some leaders precisely because it is seen as systematic , methodical and measurable. (The hidden Taylor in our thinking

The Highest Paid Person’s Opinion (HIPPO) usually has significant sway, regardless of the age of the tools (Taylorism 1911) , or the tools’ re-introduction under a cool new title (Lean Production) Dankbaar [1997] claims that lean production appears as an extension rather than a successor to Tayloristic mass production system.

2) Flexible Tools : (When Resilience Engineering makes sense)

Manage what you can't measure: Edward Deming (Father of Quality Management) is often incorrectly quoted as saying: "you can't manage what you can't measure." In fact, he stated one of the seven deadly diseases of management was running a company on visible figures alone. ( Out of the Crisis, page 121)

When problems of the organization have to do with complexity or unforeseen interactions , (even if these are normal every day events) , a resilience perspective may be helpful . Some things need standardization (such as routine processes) and some things require flexibility(adaptation)to cope with the situation at hand.
The handover work we have done seeks to achieve this balance ( a flexible standard) and in so doing applies the 4 features of resilience; Learn/ Anticipate/ Respond / Monitor (LARM ) ,all of which are features of effective handover communication. The first and most important element has been using anticipatory questions

3) How do I promote the Safety II idea ? – I make System Diagnoses: Examining Work as Done

I find most ex-clinicians leaders & clinicians respond to the view from the ground. Focussing control on how the work is done is tayloristic thinking (Work as Imagined) . For common , seemingly intractable problems , I use direct observation of work as done , and it applies the whole bottom up mantra. It is labour intensive but yields surprizing results which are generated by the clinicians themselves. The leaders can hardly argue with these “home grown” improvements .

Recent examples of resilience thinking applied are; direct observation +/- human factors usability
1) Clinical handover on an inpatient psychiatric unit (balancing brevity & relevance)
2) Usability analysis of infusion pumps involving 20 RNs in clinical scenerios
3) Nursing students observing RNs doing independent double check for high risk medications (what works, what does not)

Finally, there is real progress on simplification (48/6 strategies to prevent functional decline)which includes standardization of documentation (reduction of waste /redundancies)and the creation of a verbal handover guideline (flexible, principle based ,requiring interaction)- resilience even…


The practical value in the Safety II perspective will be apparent when applied alongside those durable Safety I habits. When Safety II shows more simple and durable results, the commitment to a Safety 1 perspective will fade.

Simplicity is the ultimate sophistication - daVinci

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Hugh MacLeod, CEO, Canadian Patient Safety Institute (CPSI)

Prior to joining CPSI in 2010, Hugh held senior positions with the Government of Ontario as associate deputy minister of the climate change secretariat and associate deputy minister for the Ontario Ministry of Health and Long-Term Care. During his four years with the ministry, he was also the executive lead of the Premier’s Health Results Team, responsible for a provincial surgical wait time strategy, a provincial primary care strategy, and the creation of local health integration networks.

Hugh has also held a number of senior executive positions in British Columbia, including senior vice-president of Vancouver Coastal Health and senior vice-president of the Health Employers Association of British Columbia.

Hugh’s professional activities include serving as senior fellow at the University of Toronto, Rotman School of Management; adjunct professor at the University of British Columbia, Faculty of Medicine; associate faculty at Royal Roads University, Victoria, Faculty of Social and Applied Science; and adjunct professor at Griffith University Business School in Brisbane Australia.



6th Resilient Health Care Meeting

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