Book of the month: Resilient Health Care (Hollnagel, Braithwaite and Wears (eds))

About the editors

Erik Hollnagel has a PhD in Psychology and is a Professor at the University of Southern Denmark and Chief Consultant at the Centre for Quality Improvement, Region of Southern Denmark. He is the chief proponent of the Safety-II paradigm and helped to coin the term "resilience engineering".
Jeffrey Braithwaite, PhD, is the director and a professor of the Australian Institute of Health Innovation and the Centre for Health Care Resilience and Implementation Science, both based in the Faculty of Medicine and Health Sciences at Macquarie University, Australia. He is also an Adjunct Professor at the University of Southern Denmark.
Robert Wears, MD, PhD, is an emergency physician and professor of emergency medicine at the University of Florida and visiting professor at the Clinical Safety Research Unit, Imperial College London.

About the contributors

There are 27 other contributors, including well-known names such as Charles Vincent and Terry Fairbanks. The contributors are a world-wide selection, encompassing the US, Europe and Australasia. The majority are from a sociological/psychological research background rather than front-line clinical. 

Who should read this book?

This book will be of interest to those who are tasked with improving patient safety within their organisation, whether this is by collecting and analysing incident reports or "teaching" healthcare workers. It would be useful reading for board members, healthcare leaders and politicians involved in healthcare.

In summary

The book is divided into 3 parts (18 chapters), as well as a preface and epilogue by the editors

1. Health care as a multiple stakeholder, multiple systems enterprise
1. Making Health Care Resilient: From Safety-I to Safety-II
2. Resilience, the Second Story, and Progress on Patient Safety
3. Resilience and Safety in Health Care: Marriage or Divorce?
4. What Safety-II Might Learn from the Socio-Cultural Critique of Safety-I
5. Looking at Success versus Looking at Failure: Is Quality Safety? Is Safety Quality?
6. Health Care as a Complex Adaptive System
2. The locus of resilience - individuals, groups, systems
7. Resilience in Intensive Care Units: The HUG Case
8. Investigating Expertise, Flexibility and Resilience in Socio-technical Environments: A Case Study in Robotic Surgery
9. Reconciling Regulation and Resilience in Health Care
10. Re-structuring and the Resilient Organisation: Implications for Heath Care
11. Relying on Resilience: Too Much of a Good Thing?
12. Mindful Organising and Resilient Health Care
3. The nature and practice of resilient health care
13. Separating Resilience from Success
14. Adaptation versus Standardisation in Patient Safety
15. The Use of PROMs to Promote Patient Empowerment and Improve Resilience in Health Care Systems
16. Resilient Health Care
17. Safety-II Thinking in Action: 'Just in Time' Information to Support Everyday Activities
18. Mrs Jones Can't Breathe: Can a Resilience Framework Help?

I haven't got the time to read 238 pages...

For the time-poor, the preface and epilogue are worth reading. Chapter 3 on the challenges resilience poses to safety, Chapter 5 on quality versus safety and Chapter 11, co-authored by Charles Vincent, on the downsides of resilience, are also worth reading.

What's good about this book?

This book makes it clear that "resilience" can mean different things to different people. The authors identify resilience as part of the defining core of a system, something a system does rather than something that it has (p.73, p.146, p.230). This is in contrast to some who call for more resilient healthcare workers, with the implication that if they were "tougher" then they would make fewer mistakes. Resilience is also not just about an ability to continue to function but an ability to minimise losses and maximise recovery (p.128).

The authors also make it clear that resilience is not a self-evident positive attribute. More resilience in a system does not come without cost including, for example, a system which may resist "positive" change, such as some of the changes that the patient safety movement is trying to embed. Safety may focus on standardisation and supervision while resilience focuses on innovation, personalisation and autonomy (p.29). In Chapter 3, René Amalberti argues that "it is not a priority to increase resilience in health care. The ultimate priority is probably to maintain natural resilience for difficult situations, and abandon some for the standard" (p.35).

The book helps to explain the lack of rapid advance in patient safety because of the "economic, social, organisational, professional, and political forces that surround healthcare" (p.21). Healthcare may be unique in the diversity and strength of these influences. In addition the authors argue that there is a gap between the front-line and those who manage "safety" (p.42), a finding echoed by Reason and Hobbs in their book on maintenance error.

The book makes a good critique of the "measure and manage" approach of Safety-I (p.41) which:

• is retrospective
• focuses on the 10%
• misses learning to be found in safe practice
• focuses on the clinical microsystem rather than the wider socio-cultural, organisational, political system 

Lastly, much work is currently focused on standardisation, however the authors argue that we should  acknowledge the inevitability of performance variability, the need to monitor it and to control it (by dampening it when it's going in the wrong direction and amplifying it when it's going in the right direction). (p.13) The standardisation that does improve resilience is the type that decreases the requirements for effortful attention or the need to memorise (e.g. checklists, layout of workplaces).

What's bad about this book?

Throughout this book, resilience is linked with the Safety-II concept (e.g. "Chapter 1: Making Health Care Resilient: From Safety-I to Safety-II"). The argument for Safety-II can be a nuanced one, therefore a good book on resilience would use simple language and provide specific examples. This book fails on the former and performs poorly on the latter. In particular, how Safety-II can be put into practice now is only vaguely referred to. Even the chapters which purport to show resilience in action do not make this very clear. Exceptions include Chapter 12 "Mindful Organising and Resilient Health Care" which suggests that people should be shown their inter-relations, i.e. how their actions affect those who interact with a patient upstream and downstream. 

At times, the championing of Safety-II gives its proponents the appearance of a cult, e.g. "Enlightened thinkers in both industry and academia began to appreciate..." (p.xxiv) while one must imagine that unenlightened thinkers continued to live in their caves. There are also attacks on the PDCA/PDSA cycle (p.177) and the use of barriers (p. 131) as Safety-I thinking. In addition Safety-I, as a term and paradigm, has been created by Safety-II advocates, and in fact "pure" Safety-I probably does not exist. For example: "In contrast to Safety-I, Safety-II acknowledges that systems are incompletely understood...", however very few people working in healthcare, even within a Safety-I system, would argue that they fully understand the system.

One of the examples in the book of proactive safety management is the stockpiling of H1N1 drugs and vaccines in 2009. This was later deplored by a number of sources as the mild epidemic killed fewer people than seasonal flu and millions of pounds of stockpiles had to be destroyed. 

Lastly one of the arguments the authors use against Safety-I thinking is that focusing on the small number of adverse events means we miss the opportunity to look at all the times things went well. However, with 10% of patients admitted to UK hospitals being subjected to iatrogenic harm (Vincent et al 2008), the number of times things go wrong is still a large chunk of the total work.

Final thoughts

This book makes a strong argument that we must stop looking purely at what has gone wrong in order to find out how to prevent mistakes. It also makes it clear that healthcare, as a complex adaptive system, will not be "fixed" by silver bullets, and that all solutions to problems create their own problems.

The concepts underpinning Safety-II, which include an urge to focus less on incidents and accidents and more on things that go well, are antithetical to much current thinking within healthcare. In addition patients and their families would not accept "I'm sorry you were harmed but we're focusing on things that go right" as an apology. This means that rather than pushing Safety-II, it may be more effective to advocate Safety-III. In Chapter 12 this is defined as: 

"... enactive safety - embodies the reactive [Safety-I] and proactive [Safety-II] and therefore both bridges the past and future, and synthesises their lessons and prospects into current action." (p.155)

Hollnagel himself says "...the way ahead does not lie in a wholesale replacement of Safety-I by Safety-II, but rather in a combination of the two ways of thinking" (p.16). Safety-III may turn out to be a quixotic Theory of Everything. Or it may mature into an accepted, practical and applied paradigm, with "a degree of autonomy at the interface with the patient, yet predictability and effectiveness at the level of the organisation" (p.132). Its adherents still have much work to do.

Further reading:

Vincent, C., et al. (2008) Is health care getting safer? British Medical Journal, 2008;337:a2426.