- Satyan Chari1, Senior Faculty, CEQ Healthcare Improvement Fellowship
- Michael Tresillian2, Program Director, CEQ Healthcare Improvement Fellowship
- Linda McCormack3, Faculty Director, CEQx, Clinical Director – Healthcare Improvement Unit
The fields of resilience engineering, Safety II and the foundational science of complex systems are starting to seed transformative shifts in many industries. For healthcare, the face validity for these ideas seems particularly high. Many clinicians have found deep resonance with the perspectives made available by complexity science and the applied fields of resilience engineering (RE) and its extensions into the safety domain. This emerging paradigm has allowed for the formal recognition of the fluidity inherent in delivering responsive clinical care, the unavoidability of adaptive decision-making, the non-linearities in developing an accurate diagnosis and the seemingly intractable nature of systems we rely on and work within. It is somewhat paradoxical that a paradigm shift towards the acknowledgment of ambiguity and uncertainty in clinical care has reinvigorated the traditional pursuits of clinical safety, quality and improvement to the degree that it has.
Clinical Excellence Queensland in Australia, through its improvement transformation institute (CEQx) has sought to establish a clinician-focused healthcare improvement leadership program but created this on a foundation of complex systems science rather than the more conventional model (derived from the process improvement literature). This program enables deep immersion of our improvement fellows in safety II and resilience engineering theory and methods whilst allowing them opportunities to test these ideas in parallel real-world improvement work. Notably, Professor Jeffrey Braithwaite’s seminal papers on creating a resilient healthcare system bookend our program’s commencement and culmination to allow fellows to meaningfully gauge their own shifts over an intense and cognitively taxing year. System-level outcomes from this unique investment into a focused group of clinicians will take some time to be fully realised but early indications are encouraging. In this article we share stories from three fellows who recently graduated the program and how the resilient healthcare paradigm has influenced their thinking and shaped their clinical improvement priorities.
Matthew Burstow is an acute surgeon and a graduand of the 2019 iteration of the healthcare improvement fellowship program. Matt recently stepped up to a leadership role as the divisional director of surgical services at Logan Hospital in the south of Brisbane. At the commencement of his fellowship, Matt sought to improve access and utilisation of operating theatres having tried process engineering methods (lean & six sigma) and having achieved mixed results.
Matt found the fellowship cohort’s foray into complex systems science reshaped his perspectives on various issues profoundly. Matt felt complexity science and RE validated deeper suspicions that variation management and waste minimisation goals were incongruent with the unpredictable and reactive reality of acute (unplanned) surgical admissions. Once Matt began to reframe his view of the system as complex, replete with myriad trade-off decisions, sensitive to externalities and subject to competitive pressures (for shared theatre resources across different surgical specialities), he came to view reliable outcomes as more closely tied to resilient performance than merely a function of improved process reliability. Matt gravitated to the functional resonance analysis method (FRAM) to model possible changes within his system. Matt found that the application of FRAM brought some of the complex inter-dependencies in his system into sharper focus, making them more explicit, and therefore more feasible to engage with. Matt noted the ability to model control functions, resource utilisation and preconditions and seeing how they interact to be revelatory. FRAM exposed the multiple appropriate ‘paths’ through which patients could enter his service and the avoidable problems that a pathway simplification focus might create. Through his application of FRAM, Matt also detected issues that could in fact benefit from optimisation, such as in reducing times spent awaiting diagnostic test results.
Since the fellowship, Matt has been actively engaging with peers to shift the surgical improvement fraternity towards a resilience engineering approach in order to better tackle problems of flow, resource utilisation and safety. As a senior leader in his hospital’s response to the COVID-19 pandemic, Matt has found the resilience engineering perspective shaping how he navigates local solutions that have emerged to manage personal protective equipment stocks and anticipatory modifications to care protocols. Matt elaborates: “The process driven thing to do would be to squash this out and enforce adherence to guidelines.”…“I’ve been letting some things go, see how they develop and whether they offer some resilience to the system”…”it was really helpful to have this foundation of knowledge of complexity in a situation like this”.
Anne Hooper is a senior nurse at Mackay Base Hospital (in regional Queensland) and is an alumnus of the 2019 fellowship program. Anne entered the program with a well-defined clinical problem to work on during her fellowship year – specifically, to improve compliance with recommended timeframes for managing emergency patients presenting with a stroke (a serious neurological condition requiring urgent care). Anne described her early months of the fellowship as frustrating on many levels. In terms of her project, Anne found herself having to periodically revisit what the ‘real’ problem was, but in retrospect recognised this as natural progression into a deeper systemic perspective of the issue. Anne recounted how she had a gradual realisation that designing a better ‘pathway’ may have been a solution for the wrong problem. Rather, Anne came to terms with the idea that the time it took to respond to patients (no matter how urgent) was an emergent property of a complex system where simple things (the availability of an open phone line to take an ambulance officer’s call) and very complicated things (access to senior medical officers who might be shared across other teams) all influenced how well orchestrated a system appeared at any point in time. Anne pivoted to a more appreciative examination of the system and how it performed under varying conditions, how clinicians thought about and prioritised tasks and ways in which positive workarounds could be enabled when conditions were less than ideal. Like Matt, Anne also found benefit in guiding her thinking and change efforts by constructing a FRAM model but en route, also discovered a newfound curiosity about how work is (actually) done.
Denise Hobson, a geriatrician and general physician with the Royal Brisbane and Women’s Hospital, joined the fellowship in 2019. Denise led a program seeking to expand an innovative service delivery model for the healthcare of residents from nursing homes across the north side of the greater Brisbane region. Denise’s natural inclination for partnership and collaboration led her to prioritise relationships with general practices in the region, with individual aged care facilities and with receiver services (emergency departments and speciality geriatric services) within the health system. Denise found that learning about complexity and systems resilience lent support for what she felt was intuitively correct, that is taking an adaptive, negotiated and relationships driven approach. Denise sought to build a sustainable person-centred service model – knitting entities that were traditionally divided and could sometimes be transactional (and even territorial) when managing vulnerable patients across the continuum of care. Denise’s immersion in complexity and resilient healthcare also shaped in subtle ways how the service was structured, the goals the team aligned to and how success was ultimately defined for the project, extending beyond the hard metrics of ‘avoided hospital admissions’.
To learn more about the CEQ Improvement fellowship program, other stories and outputs from our alumni, please get in touch at improvementfellowship@health.qld.gov.au or email the faculty directly.