Healthcare team resilience during COVID-19: a qualitative study.

BACKGROUND: Resilience, in the field of Resilience Engineering, has been identified as the ability to maintain the safety and the performance of healthcare systems and is aligned with the resilience potentials of anticipation, monitoring, adaptation, and learning. In early 2020, the COVID-19 pandemic challenged the resilience of US healthcare systems due to the lack of equipment, supply interruptions, and a shortage of personnel. The purpose of this qualitative research was to describe resilience in the healthcare team during the COVID-19 pandemic with the healthcare team situated as a cognizant, singular source of knowledge and defined by its collective identity, purpose, competence, and actions, versus the resilience of an individual or an organization. METHODS: We developed a descriptive model which considered the healthcare team as a unified cognizant entity within a system designed for safe patient care. This model combined elements from the Patient Systems Engineering Initiative for Patient Safety (SEIPS) and the Advanced Team Decision Making (ADTM) models. Using a qualitative descriptive design and guided by our adapted model, we conducted individual interviews with healthcare team members across the United States. Data were analyzed using thematic analysis and extracted codes were organized within the adapted model framework. RESULTS: Five themes were identified from the interviews with acute care professionals across the US (N = 22): teamwork in a pressure cooker, consistent with working in a high stress environment; healthcare team cohesion, applying past lessons to present challenges, congruent with transferring past skills to current situations; knowledge gaps, and altruistic behaviors, aligned with sense of duty and personal responsibility to the team. Participants' described how their ability to adapt to their environment was negatively impacted by uncertainty, inconsistent communication of information, and emotions of anxiety, fear, frustration, and stress. Cohesion with co-workers, transferability of skills, and altruistic behavior enhanced healthcare team performance. CONCLUSION: Working within the extreme unprecedented circumstances of COVID-19 affected the ability of the healthcare team to anticipate and adapt to the rapidly changing environment. Both team cohesion and altruistic behavior promoted resilience. Our research contributes to a growing understanding of the importance of resilience in the healthcare team. And provides a bridge between individual and organizational resilience.

A resilience view on health system resilience: a scoping review of empirical studies and reviews.

BACKGROUND: Prompted by recent shocks and stresses to health systems globally, various studies have emerged on health system resilience. Our aim is to describe how health system resilience is operationalised within empirical studies and previous reviews. We compare these to the core conceptualisations and characteristics of resilience in a broader set of domains (specifically, engineering, socio-ecological, organisational and community resilience concepts), and trace the different schools, concepts and applications of resilience across the health literature. METHODS: We searched the Pubmed database for concepts related to 'resilience' and 'health systems'. Two separate analyses were conducted for included studies: a total of n = 87 empirical studies on health system resilience were characterised according to part of health systems covered, type of threat, resilience phase, resilience paradigm, and approaches to building resilience; and a total of n = 30 reviews received full-text review and characterised according to type of review, resilience concepts identified in the review, and theoretical framework or underlying resilience conceptualisation. RESULTS: The intersection of health and resilience clearly has gained importance in the academic discourse with most papers published since 2018 in a variety of journals and in response to external threats, or in reference to more frequent hospital crisis management. Most studies focus on either resilience of health systems generally (and thereby responding to an external shock or stress), or on resilience within hospitals (and thereby to regular shocks and operations). Less attention has been given to community-based and primary care, whether formal or informal. While most publications do not make the research paradigm explicit, 'resilience engineering' is the most prominent one, followed by 'community resilience' and 'organisational resilience'. The social-ecological systems roots of resilience find the least application, confirming our findings of the limited application of the concept of transformation in the health resilience literature. CONCLUSIONS: Our review shows that the field is fragmented, especially in the use of resilience paradigms and approaches from non-health resilience domains, and the health system settings in which these are used. This fragmentation and siloed approach can be problematic given the connections within and between the complex and adaptive health systems, ranging from community actors to local, regional, or national public health organisations to secondary care. Without a comprehensive definition and framework that captures these interdependencies, operationalising, measuring and improving resilience remains challenging.

Slack in the infrastructure of intensive care units: resilience management in the post-pandemic era.

BACKGROUND: Although slack is an asset to resilient hospitals, it is usually explicitly discussed only in terms of the quantity and quality of beds and staff. This paper expands this view by addressing slack in four infrastructures of intensive care units (ICUs) (physical space, electricity supply, oxygen supply, and air treatment) during the COVID pandemic. METHODS: The study occurred in a leading private hospital in Brazil, aiming at the identification of slack in four units originally designed as ICUs and two units adapted as ICUs. Data collection was based on 12 interviews with healthcare professionals, documents, and comparison between infrastructures and regulatory requirements. RESULTS: Twenty-seven instantiations of slack were identified, with several indications that the adapted ICUs did not provide infrastructure conditions as good as the designed ones. Findings gave rise to five propositions addressing: relationships intra and inter infrastructures; the need for adapted ICUs that match as closely as possible the designed ICUs; the consideration of both clinical and engineering perspectives in design; and the need for the revision of some requirements of the Brazilian regulations. CONCLUSIONS: Results are relevant to both the designers of the infrastructures and to the designers of clinical activities as these must take place in fit-for-purpose workspaces. Top management might also benefit as they are the ultimate responsible for decision-making on whether or not to invest in slack. The pandemic dramatically demonstrated the value of investing in slack resources, creating momentum for this discussion in health services.

Effect of improvement measures in reducing interruptions in a Japanese hospital pharmacy using a synthetic approach based on resilience engineering and systems thinking.

BACKGROUND: Workflow interruptions in pharmacies contribute to dispensing errors, a high-priority issue in patient safety, but have rarely been studied from a systemic perspective partly because of the limitations of the conventional reductionistic approach. This study aims to identify a mechanism for the occurrence of interruptions in a hospital pharmacy and find interventional points using a synthetic approach based on resilience engineering and systems thinking, and assess implemented measures for reducing them. METHODS: At a Japanese university hospital, we gathered information about performance adjustments of pharmacists in the inpatient medication dispensing unit for oral and topical medicines (IMDU-OT) and nurses in the inpatient wards (IPWs) in the medication dispensing and delivery process. Data about the workload and workforce of pharmacists were collected from hospital information systems. Telephone inquiries and counter services in the IMDU-OT, the primary sources of interruptions to pharmacists' work, were documented. The feedback structure between the IMDU-OT and the IPWs was analyzed using a causal loop diagram to identify interventional points. The numbers of telephone calls and counter services were measured cross-sectionally before (February 2017) and four months after implementing measures (July 2020). RESULTS: This study found that interruptions are a systemic problem emerging from the adaptive behavior of pharmacists and nurses to their work constraints, such as short staffing of pharmacists, which limited the frequency of medication deliveries to IPWs, and lack of information about the medication dispensing status for nurses. Measures for mitigating cross-system performance adjustments-a medication dispensing tracking system for nurses, request-based extra medication delivery, and pass boxes for earlier pick-up of medicines-were introduced. Following their implementation, the daily median number of telephone calls and counter services was significantly reduced (43 to 18 and 55 to 15, respectively), resulting in a 60% reduction in the total number of interruptions. CONCLUSION: This study found interruptions in the hospital pharmacy as a systemic problem that can be reduced by mitigating difficulties being compensated for by clinicians' cross-system performance adjustments. Our findings suggest that a synthetic approach can be effective for solving complex problems and have implications for methodological guidance for Safety-II in practice.

Resilience is a dirty word: misunderstood, and how we can truly build it.

Resilience is ubiquitous in everyday speech, academic literature and governmental policies. Yet it seems to have taken a narrow scope in healthcare, confined to individual and psychological resilience. This short essay aims to broaden the understanding of resilience to organisational levels and calls intensivists to take active roles in fostering resilience for their staff. The article explores firstly the background and etymology of resilience. It then challenges current approaches and briefly signposts some current work in the area. Some examples of structural factors which build individual resilience are listed, followed by a call for intensivists to take active roles to build future resilience. The need for interdisciplinary, cross-sectoral and multi-level approaches is vital to build future healthcare resilience, and we intensivists must continue to be advocates for systemic change.

Adaptations to practice and resilience in a paediatric major trauma centre during a mass casualty incident.

BACKGROUND: Innovation and human adaptation in the face of unfolding catastrophe is the cornerstone of an effective systemwide response. Capturing, analysing, and disseminating this is fundamental in developing resilience for future events. The aim of this study was to understand the characteristics of adaptations to practice early in a paediatric major trauma centre during a mass casualty incident. METHODS: A qualitative interview study of 40 healthcare staff at a paediatric major trauma centre in the immediate aftermath of a terrorist bombing was conducted. An inductive thematic analysis approach was used, followed by a deductive analysis of the identified adaptations informed by constructs of resilience engineering. RESULTS: Five themes of adaptations to practice that enhanced the resilient performance of the hospital were identified: teamworking; psychologically supporting patients, families, and staff; reconfiguring infrastructure; working around the hospital electronic systems; and maintaining hospital safety. Examples of resilience potential in terms of respond, monitor, anticipate, and learn are presented. CONCLUSIONS: Our study shows how adaptations to practice sustained the resilient performance of a paediatric major trauma centre during a mass casualty incident. Rapid, early capture of these data during a mass casualty incident provides key insights into enhancing future emergency preparedness, response, and resilience planning.

A qualitative formative evaluation of a patient facing intervention to improve care transitions for older people moving from hospital to home.

BACKGROUND: The Partners at Care Transitions (PACTs) intervention was developed to support older people's involvement in hospital to improve outcomes at home. A booklet, question card, record sheet, induction leaflet, and patient-friendly discharge letter support patients to be more involved in their health and wellbeing, medications, activities of daily living and post-discharge care. We aimed to assess intervention acceptability, identify implementation tools, and further develop the intervention. METHODS: This was a qualitative formative evaluation involving three wards from one hospital. We recruited 25 patients aged 75 years and older. Ward staff supported intervention delivery. Data were collected in wards and patients' homes, through semi-structured interviews, observation, and documentary analysis. Data were analysed inductively and iteratively with findings sorted according to the research aims. RESULTS: Patients and staff felt there was a need for, and understood the purpose of, the PACT intervention. Most patients read the booklet but other components were variably used. Implementation challenges included time, awareness, and balancing intervention benefits against risks. Changes to the intervention and implementation included clarifying the booklet's messages, simplifying the discharge letter to reduce staff burden, and using prompts and handouts to promote awareness. CONCLUSION: The PACT intervention offers a promising new way to improve care transitions for older people by supporting patient involvement in their care. After further development of the intervention and implementation package, it will undergo further testing. PATIENT OR PUBLIC CONTRIBUTION: This study regularly consulted a panel representing the local patient community, who supported the development of this intervention and its implementation.

An integrated quality and resilience engineering framework in healthcare with Z-number data envelopment analysis.

Supplier selection for medical equipment is a major challenge for hospitals in healthcare supply chains. The primary reason for measuring medical equipment supplier efficiency is to achieve the highest level of overall performance and productivity in healthcare supply chains. This study presents an integrated quality and resilience engineering (QRE) framework for evaluating medical equipment suppliers' performance using structural equation modeling and Z-number data envelopment analysis (Z-DEA). Noise analysis is used to select the best α-cut for the Z-DEA model, and fuzzy data are used to handle uncertainties. We show that flexibility, conformance to standards, redundancy, cost, quality certifications, and delivery time significantly affect the medical equipment suppliers' performance. In addition, we demonstrate that the proposed integrated QRE framework is more efficient and informative than stand-alone quality engineering or resiliency engineering. We present a case study in a cardiovascular hospital to illustrate the applicability of the proposed framework for medical equipment supplier evaluation and selection. To the best of our knowledge, this is the first study to integrate QRE and Z-DEA for supplier performance evaluation in healthcare.

Simulation-Based Resilience Quantification of an Indoor Ultrasound Localization System in the Presence of Disruptions.

Time difference of arrival (TDOA) based indoor ultrasound localization systems are prone to multiple disruptions and demand reliable, and resilient position accuracy during operation. In this challenging context, a missing link to evaluate the performance of such systems is a simulation approach to test their robustness in the presence of disruptions. This approach cannot only replace experiments in early phases of development but could also be used to study susceptibility, robustness, response, and recovery in case of disruptions. The paper presents a simulation framework for a TDOA-based indoor ultrasound localization system and ways to introduce different types of disruptions. This framework can be used to test the performance of TDOA-based localization algorithms in the presence of disruptions. Resilience quantification results are presented for representative disruptions. Based on these quantities, it is found that localization with arc-tangent cost function is approximately 30% more resilient than the linear cost function. The simulation approach is shown to apply to resilience engineering and can be used to increase the efficiency and quality of indoor localization methods.

A Resilience-Based Approach to Risk Assessments-Building Resilient Organizations under Arctic Conditions.

Reliability and higher levels of safety are thought to be achieved by using systematic approaches to managing risks. The assessment of risks has produced a range of different approaches to assessing these uncertainties, presenting models for how risks affect individuals or organizations. Contemporary risk assessment tools based on this approach have proven difficult for practitioners to use as tools for tactical and operational decision making. This article presents an alternative to these assessments by utilizing a resilience perspective, arguing that complex systems are inclined to variety and uncertainty regarding the results they produce and are therefore prone to systemic failures. A continuous improvement approach is a source of reliability when managing complex systems and is necessary to manage varieties and uncertainties. For an organization to understand how risk events occur, it is necessary to define what is believed to be the equilibrium of the system in time and space. By applying a resilience engineering (RE) perspective to risk assessment, it is possible to manage this complexity by assessing the ability to respond, monitor, learn, and anticipate risks, and in so doing to move away from the flawed frequency and consequences approach. Using a research station network in the Arctic as an example illustrates how an RE approach qualifies assessments by bridging risk assessments with value-creation processes. The article concludes by arguing that a resilience-based risk assessment can improve on current practice, including for organizations located outside the Arctic region.

Toward General Principles for Resilience Engineering.

Maintaining the performance of infrastructure-dependent systems in the face of surprises and unknowable risks is a grand challenge. Addressing this issue requires a better understanding of enabling conditions or principles that promote system resilience in a universal way. In this study, a set of such principles is interpreted as a group of interrelated conditions or organizational qualities that, taken together, engender system resilience. The field of resilience engineering identifies basic system or organizational qualities (e.g., abilities for learning) that are associated with enhanced general resilience and has packaged them into a set of principles that should be fostered. However, supporting conditions that give rise to such first-order system qualities remain elusive in the field. An integrative understanding of how such conditions co-occur and fit together to bring about resilience, therefore, has been less clear. This article contributes to addressing this gap by identifying a potentially more comprehensive set of principles for building general resilience in infrastructure-dependent systems. In approaching this aim, we organize scattered notions from across the literature. To reflect the partly self-organizing nature of infrastructure-dependent systems, we compare and synthesize two lines of research on resilience: resilience engineering and social-ecological system resilience. Although some of the principles discussed within the two fields overlap, there are some nuanced differences. By comparing and synthesizing the knowledge developed in them, we recommend an updated set of resilience-enhancing principles for infrastructure-dependent systems. In addition to proposing an expanded list of principles, we illustrate how these principles can co-occur and their interdependencies.

Exploring organisational competences in Human Factors and UX project work: managing careers, project tactics and organisational strategy.

Organisational competence in Human Factors and UX (user experience) has not been looked at before despite its relevance to project success. We define organisational competence as the collective competence of the individuals, bringing together their complementary abilities to deliver an outcome that is typically more than the sum of its parts. Twenty-two UX and Human Factors practitioners were interviewed about their project work in two contrasting domains: web design and safety-critical systems to explore organisational competences. Through doing a FRAM analysis, 29 functions and 6 main areas of competences were identified: the central project process; the process of learning about the problem; maintaining and developing client relations; staff development; evolving practices; and the management of documentation for audit and quality control. These dynamic and situated competences form a web of interactions. Managing competences is essential for project success. Implications for managing careers, project tactics and organisational strategy are discussed. Practitioner Summary: Organisational competences impact how routine and non-routine project work is performed, but these have received little attention in the literature. Six key areas of competences in Human Factors and UX project work were identified from practitioner interviews. Managing combinations of adaptive competences is important for developing careers, project tactics and organisational strategies.

An intelligent algorithm for optimizing emergency department job and patient satisfaction.

Purpose Resilience engineering, job satisfaction and patient satisfaction were evaluated and analyzed in one Tehran emergency department (ED) to determine ED strengths, weaknesses and opportunities to improve safety, performance, staff and patient satisfaction. The paper aims to discuss these issues. Design/methodology/approach The algorithm included data envelopment analysis (DEA), two artificial neural networks: multilayer perceptron and radial basis function. Data were based on integrated resilience engineering (IRE) and satisfaction indicators. IRE indicators are considered inputs and job and patient satisfaction indicators are considered output variables. Methods were based on mean absolute percentage error analysis. Subsequently, the algorithm was employed for measuring staff and patient satisfaction separately. Each indicator is also identified through sensitivity analysis. Findings The results showed that salary, wage, patient admission and discharge are the crucial factors influencing job and patient satisfaction. The results obtained by the algorithm were validated by comparing them with DEA. Practical implications The approach is a decision-making tool that helps health managers to assess and improve performance and take corrective action. Originality/value This study presents an IRE and intelligent algorithm for analyzing ED job and patient satisfaction - the first study to present an integrated IRE, neural network and mathematical programming approach for optimizing job and patient satisfaction, which simultaneously optimizes job and patient satisfaction, and IRE. The results are validated by DEA through statistical methods.

[Analysis of Preventive Cases Using Resilience Engineering in Radiotherapy Department].

PURPOSE: Resilience engineering is the ability of a system to adjust its own functions and maintain the required behavior in the face of changes and disturbances, and resilience potential is a necessary requirement. We aimed to clarify the relationship between resilience potential and error prevention cases. METHOD: Based on the error cases reported in our department, we aggregated the relationship with resilience potential for each radiation treatment process. RESULT: As a result of tabulating the relationship, we were able to recognize and prevent errors by taking preventive measures from past cases. On the other hand, in cases that slipped through the check mechanism, errors were discovered because of a sense of discomfort in unusual situations, and some error cases could be prevented by increasing the resilience potential. CONCLUSION: This study found that preparation, observation, coping, and utilization of past experiences are related to resilience potential in preventive cases.

Methods for studying medication safety following electronic health record implementation in acute care: a scoping review.

OBJECTIVES: The objective of this scoping review is to map methods used to study medication safety following electronic health record (EHR) implementation. Patterns and methodological gaps can provide insight for future research design. MATERIALS AND METHODS: We used the Joanna Briggs Institute scoping review methodology and a custom data extraction table to summarize the following data: (1) study demographics (year, country, setting); (2) study design, study period, data sources, and measures; (3) analysis strategy; (4) identified limitations or recommendations; (5) quality appraisal; and (6) if a Safety-I or Safety-II perspective was employed. RESULTS: We screened 5879 articles. One hundred and fifteen articles met our inclusion criteria and were assessed for eligibility by full-text review. Twenty-seven articles were eligible for extraction. DISCUSSION AND CONCLUSION: We found little consistency in how medication safety following EHR implementation was studied. Three study designs, 7 study settings, and 10 data sources were used across 27 articles. None of the articles shared the same combination of design, data sources, study periods, and research settings. Outcome measures were neither defined nor measured consistently. It may be difficult for researchers to aggregate and synthesize medication safety findings following EHR implementation research. All studies but one used a Safety-I perspective to study medication safety. We offer a conceptual model to support a more consistent approach to studying medication safety following EHR implementation.

What is diagnostic safety? A review of safety science paradigms and rethinking paths to improving diagnosis.

Diagnostic errors in health care are a global threat to patient safety. Researchers have traditionally focused diagnostic safety efforts on identifying errors and their causes with the goal of reducing diagnostic error rates. More recently, complementary approaches to diagnostic errors have focused on improving diagnostic performance drawn from the safety sciences. These approaches have been called Safety-II and Safety-III, which apply resilience engineering and system safety principles, respectively. This review explores the safety science paradigms and their implications for analyzing diagnostic errors, highlighting their distinct yet complementary perspectives. The integration of Safety-I, Safety-II, and Safety-III paradigms presents a promising pathway for improving diagnosis. Diagnostic researchers not yet familiar with the various approaches and potential paradigm shift in diagnostic safety research may use this review as a starting point for considering Safety-I, Safety-II, and Safety-III in their efforts to both reduce diagnostic errors and improve diagnostic performance.

Resilient performance in building maintenance: A macro-cognition perspective during sudden breakdowns.

Building maintenance encompasses multiple tightly inter-connected agents (e.g., technicians, occupants, supervisors, and equipment). Variable working conditions and limited resources may affect the safety and sustainability of the activities. Although recent studies have explored how complex systems can perform resilient behavior in facing the complexity of everyday activities, the factors that effectively contribute to resilient performance are still paired with limited empirical evidence. We studied the performance of the maintenance team during sudden breakdowns of air-conditioning devices in a large university campus, using the Functional Resonance Analysis Method (FRAM). A FRAM diagram containing 30 functions was organized including six macro-cognitive functions (expertise, sensemaking, communication, coordination, collaboration, and adaptation/improvisation), examining their role in anticipating, and responding to emergencies, and eight functional units that are directly impacted by disturbances were analyzed in more detail. Results indicate that macro-cognitive functions can greatly impact the functionality of the maintenance team in pursuit of their goals. Moreover, we noted those macro-cognitive functions here analyzed depend on each other to produce resilient performance.

The Assessment and Response of Rehabilitation Professionals to Sudden Deterioration in Symptoms: An Analysis of the National Database in Japan.

OBJECTIVE: There are few analyses of the current status of and responses to acute deteriorations encountered by physiotherapists, occupational therapists, and speech-language pathologists (rehabilitation professions [RPs]). The purpose of this study was to analyze the responses of RPs to acute deterioration in patients using the functional resonance analysis method (FRAM) based on the descriptions in "the Medical Accident Database". METHODS: Subjects were 413 cases with medical incidents reported by RPs to the database from 2012 to 2021. Life-threatening cases with changes in consciousness, circulation, and respiration were selected. Descriptions regarding findings assessed by RPs and support team, and requests for assistance were extracted. We also attempted to construct appropriate respond in RPs by using the FRAM. RESULTS: Thirty-nine cases of acute deterioration were included in the analysis, and descriptions by RPs of consciousness (35 cases), circulation (18 cases), and respiration (36 cases) were identified. Blood pressure and percutaneous oxygen saturation measurement were frequently presented in the assessment by RPs, whereas the support team assessed cardiac arrest and respiratory arrest in high frequency. The FRAM analysis indicated that appropriate and rapid post-response by RPs requires patient information in prior, appropriate assessment and integration/interpretation. CONCLUSION: We attempted to identify problems analyzing the response by RPs to acute deterioration using the database and construct an appropriate response model. It resulted that RPs need to obtain patient information in advance and integrate/interpret it appropriately based on accurate assessment of conscious, circulation and respiration for rapid response. A model including integration/interpretation for appropriate post-response by RPs was constructed using the FRAM.

Managing Complexity in Socio-Technical Systems by Mimicking Emergent Simplicities in Nature: A Brief Communication.

In the context of socio-technical systems, traditional engineering approaches are inadequate, calling for a fundamental change in perspective. A different approach encourages viewing socio-technical systems as complex living entities rather than through a simplistic lens, which enhances our understanding of their dynamics. However, these systems are designed to facilitate human activities, and the goal is not only to comprehend how they operate but also to guide their function. Currently, we lack the appropriate terminology. Hence, we introduce two principal concepts, simplexity and complixity, drawing inspiration from how nature conceals intricate mechanisms beneath straightforward, user-friendly interfaces.