Healthcare is increasingly complex, with multiple stakeholders, sophisticated treatments and technologically-complicated ways of delivering care. With increasing populations and unprecedented rises in chronic disease, examining effective ways to build networked health systems is essential to help tackle these ‘wicked’ problems. We will deal with the question of why, after decades of improving health care, patients still receive care that is highly variable, frequently inappropriate, and, too often, unsafe. We will also discuss new ways of dealing with those challenges.
Resilience is a construct that defines the ability of a system to adjust its functioning prior to, during or following changes to sustain routine performance under both expected or unexpected conditions. Health systems exhibit resilience through workarounds and trade-offs, with clinicians responding to events or circumstances which effect the everyday flow of work. Staff at the ‘sharp-end’ of care flex and adjust to changes, and don’t always deliver care the way ‘blunt-end’ prescriptivists think they do.
Over 10 years ago, those who were thinking about innovation in patient safety research began to distinguish between trying to make sure things don’t go wrong and trying to make sure things go right. These two approaches came to be labelled Safety-I, where the number of adverse outcomes is as low as possible, and Safety-II, where the number of acceptable outcomes is as high as possible. Safety-I and Safety-II approaches are key to understanding resilience. The traditional Safety-I approach focuses on when things go wrong during routine performance and seeks to apply ‘find-and-fix’ solutions. However, very few people in the past had looked at how often things go right, neglecting to understand the everyday performance which unfolds on the front lines of care. This Safety-II focus seeks to recognise the ability of those at the sharp-end to succeed under varying conditions.
As we prepare to meet ever-more healthcare demands, we need to examine the properties of healthcare systems which can meet the goals we have for better, safer and more evidence-based care. By applying a Safety-II lens and deepening our understanding of resilient performance we can sharpen our understanding of how everyday clinical work is carried out under pressure in inter-dependent networked systems of care.
