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Special article

Institutional resilience in healthcare systems

J Carthey, M R de Leval, J T Reason

Introduction

A recent report for the President of the UnitedStates described the impact of preventablemedical errors as a national problem ofepidemic proportions.1 Similar concerns havebeen echoed in the report of an expert groupchaired by the Chief Medical OYcer.2 In thisreport it was estimated that 400 people in theUK die or are seriously injured each year inadverse events involving medical devices, andthat harm to patients arising from medical

errors occurs in around 10% of admissionsorat a rate in excess of 850 000 per year. The costto the NHS in additional hospital stays alone isestimated at around 2 billion a year.

The positive f ace of safety

Safety has two faces. The negative face is veryobvious and is revealed by adverse events, mis-haps, near misses, and so on. This aspect is veryeasily quantified and so holds great appeal as asafety measure. The other, somewhat hidden,aspect oVers a more satisfactory means ofassessing safety. This positive face can bedefined as the systems intrinsic resistance to itsoperational hazards. Some organisations will

be more robust in coping with the human andtechnical dangers associated with their dailyactivities. This will be as true for healthcare

institutions as it is for other systems engaged inhazardous activities. In short, some organisa-tions will be in better safety health thanothers.

The safety spaceThe ideas of resistance and vulnerability can berepresented as the extremes of a notional spacetermed the safety space (fig 1). The horizon-tal axis of the space runs from an extreme ofmaximum attainable resistance (to operational

hazards) on the left to a maximum of survivablevulnerability on the right. A number ofhypothetical organisations are located alongthis resistance vulnerability dimension. Thecigar-shaped space shows that most organisa-tions will occupy an approximately centralposition with very few located at eitherextreme.

Organisations are free to move along thisspace in either direction. In so doing, they aresubject to two kinds of forces: those existingwithin the space itself and those emanatingfrom inside the organisation. The currentswithin the space act inwards from eitherextreme (fig 2). If the organisation drifts too

close to the vulnerable end, it is likely to suV

eradverse events. These, in turn, will bring aboutinternal and external pressures to becomemore resilient. However, these safety enhanc-ing measures are not always sustained, so thatthe organisation will drift once again towardsthe vulnerable extreme. When subject solely tothe forces acting within the space, organisa-tions will tend to drift to and fro between theextremes of the space.

Managing system safety in health careThe only realistic goal of safety management isto achieve, not zero adverse events, but themaximum degree of intrinsic resistance con-

sistent with the organisations reasons for exist-ence (fig 3). There are two requirements inorder to drive the organisation towards theresistant end of the safety space, and then tokeep it there. Firstly, eVective navigational aidsare needed to indicate its current locationwithin the space. Two kinds of navigationalaids are necessary: reactive outcome measuresand proactive process measures. Secondly, itneeds some motive force to overcome theexternal forces and to maintain a fixed heading.Three cultural drivers provide the necessaryengine: commitment, competence, and cogni-sance (the three Cs). These in turn should

Figure 1 A number of hypothetical organisations distributed through the safety space.

Organisations

Increasing resistance Increasing vulnerability

Figure 2 Forces acting away from the extremes of the safety space.

Forces acting

within the

safety space

Quality in Health Care 2001;10:2932 29

Cardiothoracic Unit,Great Ormond StreetHospital for Children

NHS Trust, LondonWC1N 3JH and theInstitute of Child

Health, LondonWC1N 1EH, UK J CartheyM R de Leval

PsychologyDepartment, TheUniversity ofManchester,

Manchester M13 9PL,UKJ T Reason

Correspondence to:Dr J Carthey, CardiothoracicUnit, Great Ormond StreetHospital for Children NHSTrust, London WC1N 3JH,UKj.carthey@ich.ucl.ac.uk

Accepted 8 January 2001

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inform and direct the institutions principles,

policies, procedures, and practices (the four

Ps).

Navigational aids

Reactive safety measures are derived from the

collection and analysis of critical incident and

near miss data. The advantages and disadvan-tages of these navigational aids have been

discussed in detail elsewhere.2 3 All such data

suVer the disadvantage of being collected after

the event. Nonetheless, they provide a richvariety of valuable information.

Proactive measures identify in advance those

factors likely to contribute to some future acci-

dent. As with the tests used to diagnose apatients state of healthfor example, blood

pressure, glomerular filtration rate, haemo-

globin and cholesterol levelssafety indicators

help to identify the latent conditions that are an

intrinsic part of any high technology system.Proactive measures involve making regular

checks upon the organisations defences and

upon its various essential processesplanning,forecasting, scheduling, budgeting, maintain-

ing, training, creating procedures, and so on.

There is no single comprehensive measure of

the organisations overall safety health. Amore detailed consideration of these diagnostic

indicators has been given elsewhere.4

EVective safety management requires the useof a combination of both reactive and proactivemeasures. Together they provide essentialinformation about the systems resilience, andhence its position within the safety space. The

main elements of their integrated usage aresummarised in table 1.

The cultural driversCOMMITMENT

Commitment has two components: motivationand resources. The motivational issue hingeson whether an organisation strives to be adomain model for good safety practices orwhether it is content merely to keep one stepahead of regulatory sanctions or litigants. Theresource issue is not just a question of money,though that is important. It also concerns the

calibre and status of those people assigned tomanage system risk and how they are perceivedwithin the organisation.

COMPETENCE

An organisation must also possess the technicalcompetence necessary to achieve enhancedsafety. Previous research has shown thatcompetence is a product of several factors,including the methods used to identify hazardsand safety critical activities, diversity andredundancy in the defences,4 5 a suYcientlyflexible and adaptive organisational struc-ture,6 7 and the collection, analysis, dissemina-tion and implementation of safety related

information.

8 9

COGNISANCE

Cognisance refers to how the organisationmakes sense of its inherent risks and hazardsthat is, its sensemaking processes.10 Cognisantorganisations maintain a state of intelligentwariness even in the absence of bad outcomes.This collective mindfulness of the everpresent risks is one of the defining characteris-tics of high reliability organisations.11

APPLYING THE THREE CS TO HEALTH CARECommitment, competence, and cognisance areillustrated in the following two hypotheticalexamples.

Hospital A invests in patient safety, asevidenced by a well resourced and highlyskilled risk management team. The ChiefExecutive has an open door policy for patientsafety, allowing staVto raise issues directly withthe highest level of management; he also goesround the wards on a weekly basis. Theperception of staV is that he is well informedand responds quickly to any problems that areraised. Trust board and directorate manage-ment meetings dedicate time to discussingsafety issues alongside financial and businessgoals. There are formal and informal commu-nication links for patient safety throughout theorganisation; in each directorate senior nurses

have set up error focus groups where theydiscuss candidly, in an open forum, errors thathave recently occurred. These focus groups arecarried out in the spirit of learning systems les-sons about safety. Similarly, adverse events andnear misses are discussed at mortality andmorbidity meetings which have cross profes-sional representation (that is, nurses, surgeons,anaesthetists, radiologists, physiotherapists,technicians, etc). A combination of reactiveand proactive navigational aids are used. Thereis a positive incident reporting culture; staVunderstand the importance of filling in incidentreports, and reporting rates are high for both

Figure 3 Summary of the driving forces and navigational aids necessary to propel anorganisation towards the region of maximum resistance.

Region of

maximum

resistance

Vulnerable

Drivers

Commitment

Competence

Cognisance

Navigational aids

Reactive

measures

Proactive

measures

Table 1 Summarising the interactions between reactive and proactive measures

Type of navigational aid

Reactive measure s Proac tive measure s

Local and organisationalconditions

Analysis of many incidentscan reveal recurrentpatterns of cause andeVect

Identify those conditions mostneeding correction, leading tosteady gains in resistance orfitness

Defences, barriers andsafeguards

Each event shows a partialor complete trajectorythrough the defences

Regular checks reveal whereholes exist now and where theyare most likely to appear next

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control of the institution. Hospital Bs patho-logical thinking about patient safety places it inthe vulnerability zone of the safety space.

Checklist for assessing institutionalresilience (CAIR)The time has come to develop methods toassess institutional resilience. Table 2 containsa 20 item checklist for assessing institutionalresilience (CAIR). CAIR was devised by

considering the impact of each of the three Cs(commitment, competence, cognisance) uponthe four Ps (principles, policies, procedures,practices). For each C, examples of positiveand negative indicators of institutional resil-ience are given.

CAIR is designed so that healthcare workerscan begin to gauge their own institutionsintrinsic resistance to adverse events. This isnot a tried and tested measure, but it doescover most of the important factors discussedin this paper (and a few more besides). It is notexpected that any one institution shouldpossess all the attributes of resilience listedhere; indeed, if that were the case it would

strain credibility. The CAIR items constitute awish list of most of the desirable features of ahigh reliability healthcare organisation forcombatting the dangers to patients posed byhuman fallibility and systemic shortcomings.The list is neither definitive norcomprehensiveour present state of knowl-edge does not permit thisbut it does outlinea model of system resilience towards whichinstitutional managers and staVmight reason-ably aspire.

Each item is scored 1, 0.5, or 0. As indicatedearlier, a score of 1620 is probably too good tobe true; scores of 815 indicate a moderate tohigh level of intrinsic resistance to human andorganisational hazards, and anything less than

5 suggests a moderate to high level ofvulnerability. It is also recommended that the

responses of people at diVerent levels of theorganisation and in diVerent professionalgroupings (within the same institution) arecompared with one another. Wide discrepan-cies between the scoring profiles of thesegroups should provide important clues to somemajor areas of concern.

Finally, a health warning. Good scores onCAIR provide no guarantee of immunity frompatient mishaps. Even the healthiest institu-

tions can still have bad events. A total score of815 suggests that you are striving hard toachieve a high degree of patient safety whilestill meeting your other institutional objectives.However, the price of patient safety is chronicunease. Complacency is the worst enemy.Human fallibility will not go away, so there willbe no final victories in the struggle for patientsafety.

Research at the Institute of Child Health and Great OrmondStreet Hospital for Children NHS Trust benefits from Researchand Development funding received from the NHS Executive.

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