Developing the Resilience Markers Framework: What is it? What is it for? Where are we

headed?

Dominic Furniss Jonathan Back & Ann Blandford

Part I: Context Setting

Part II: Introduction to RMF

Part III: RMF in the Day Care Unit

Resilience• Ability to recover from unexpected events• Avoid accidents despite poor circumstance• Promote things a system does well rather than

reduce risk• Concerned with performance outside design basis

and outside formalised procedures• Commonly innovative, but also mundane• Commonly shocking, but also everyday

Part I: Context Setting

Summary• People make errors everyday• We develop resilience strategies to reduce and

mitigate these errors• These strategies form part of our resilience

repertoire• Big R is for the stage of innovation• Little r is where strategies are shared

• What resilience behaviours can we observe at the sharp-end?

• Is there a framework or method that can help us?

Reference: Furniss, Back, Blandford, Hildebrandt & Borberg (2011). A Resilience Markers Framework for Small Teams. Reliability Engineering and System Safety.

Part II: Intro to RMF

2. Strategy Level

1. Markers Level

3. Observational Level

RMFHard to understand application

Hard to generalise to other contexts

2. Strategy Level

1. Markers Level

3. Observational Level

RMF

Changing alarm system parameters so whenthe alarms go off they provide more usefulinformation about change (Mumaw et al. 2000) - Nuclear

Create a new indicator (Mumaw et al. 2000)

Maximising information extraction (Mumaw et al. 2000)

Vertical traceability

2. Strategy Level

1. Markers Level

3. Observational Level

RMF

The SS advised the operator to put a paper clip in the procedures so they could return to it more easilyFurniss et al. (2011) – Nuclear

Create a new indicator (Mumaw et al. 2000)

Maximising information extraction (Mumaw et al. 2000)

Horizontal traceability- Within domain

2. Strategy Level

1. Markers Level

3. Observational Level

RMF

Changing alarm system parameters so whenthe alarms go off they provide more usefulinformation about change (Randell, 2004) – ITU or ICU

Create a new indicator (Mumaw et al. 2000)

Maximising information extraction (Mumaw et al. 2000)

Horizontal traceability- Between domains

2. Strategy Level

1. Markers Level

3. Observational Level

RMF

i). Resilience repertoire

2. Strategy Level

1. Markers Level

3. Observational Level

RMF

i). Resilience repertoire

ii). Mode of operation

2. Strategy Level

1. Markers Level

3. Observational Level

RMF

i). Resilience repertoire

ii). Mode of operation

iii). Resources & enabling

conditions

2. Strategy Level

1. Markers Level

3. Observational Level

RMF

i). Resilience repertoire

ii). Mode of operation

iv). Vulnerabilities & Opportunities

iii). Resources & enabling

conditions

Summary• Vertical traceability• Horizontal traceability• Core of Markers – Strategies – Observations• Four elements expands strategy level:

repertoire, mode of operation, enabling conditions, and vulnerability or opportunity

Could this framework provide leverage for understanding resilience strategies at the sharp-end in healthcare contexts?

Part III: RMF in DCU

Method

• Five days observation in busy Haematology and Oncology Day Care Unit (DCU)

• 31 infusion pump interactions were observed alongside observations of DCU practices

• Data was reanalysed in terms of RMF

Results – Six Resilience Episodes

1. The trolley as a unit of work 2. Monitoring community practice3. Reducing error when using 2 pumps4. Workload management5. Swapping pumps when battery low6. Preparing for a power outage

2. Strategy Level

1. Markers Level - preparation

3. Observational Level – an experienced nurse told an new nurse to tidy the trolley after treatment. Insight – trolley’s represent units of work.

i). Resilience repertoire – using

environment to organise units of

work

ii). Mode of operation – ??

iv). Vulnerabilities & Opportunities – treatment and

patients

iii). Resources & enabling

conditions – mobile trolleys

Results – Six Resilience Episodes

1. The trolley as a unit of work2. Monitoring community practice 3. Reducing error when using 2 pumps

Workload management4. Swapping pumps when battery low5. Preparing for a power outage

2. Strategy Level

1. Markers Level - monitoring

3. Observational Level – an experienced nurse told an new nurse to tidy the trolley after treatment. Insight – nurses monitoring activity.

i). Resilience repertoire – nurses monitor to protect

accepted behaviour

ii). Mode of operation –

Monitoring when new nurses or

agency staff present

iv). Vulnerabilities & Opportunities –

accepted practices are not followed

iii). Resources & enabling

conditions – expertise in

experienced nurses

Results – Six Resilience Episodes

1. The trolley as a unit of work2. Monitoring community practice3. Reducing error when using 2 pumps 4. Workload management5. Swapping pumps when battery low6. Preparing for a power outage

2. Strategy Level

1. Markers Level - preparation

3. Observational Level – nurse used stand’s arms to physically separate medication and prepared pumps separately

i). Resilience repertoire – separating

information streams

ii). Mode of operation – using 2

pumps at same time

iv). Vulnerabilities & Opportunities – confusing rates,

times, medication

iii). Resources & enabling

conditions – stand with two arms

Results – Six Resilience Episodes

1. The trolley as a unit of work2. Monitoring community practice3. Reducing error when using 2 pumps4. Workload management 5. Swapping pumps when battery low6. Preparing for a power outage

2. Strategy Level

1. Markers Level – managing workload

3. Observational Level – nurses took on more patients than they ought and agency nurses were hired to help

i). Resilience repertoire –

employing additional operators & team

coordination

ii). Mode of operation – over

capacity for individual staff and

unit

iv). Vulnerabilities & Opportunities –

threat of staff going sick due to stress &

less rigour

iii). Resources & enabling

conditions – agency staff & flexible

workforce

Results – Six Resilience Episodes

1. The trolley as a unit of work2. Monitoring community practice3. Reducing error when using 2 pumps4. Workload management5. Swapping pumps when battery low 6. Preparing for a power outage

2. Strategy Level

1. Markers Level – awareness of performance vulnerabilities

3. Observational Level – nurses said that batteries run low toward the end of the day for long treatment cycles

i). Resilience repertoire –

remember to check battery indicator for

long cycles

ii). Mode of operation – patients on all day treatments

iv). Vulnerabilities & Opportunities –

Need to plug in or swap infusion pump

iii). Resources & enabling

conditions – spare infusion pumps

Results – Six Resilience Episodes

1. The trolley as a unit of work2. Monitoring community practice3. Reducing error when using 2 pumps4. Workload management5. Swapping pumps when battery low 6. Preparing for a power outage

2. Strategy Level

1. Markers Level – preparation

3. Observational Level – senior nurse came into the unit to warn of an expected power outage

i). Resilience repertoire –

planning for novel event

ii). Mode of operation – planning

iv). Vulnerabilities & Opportunities – expected power

outage

iii). Resources & enabling

conditions – forewarning

Conclusion from DCU study• RMF helped reveal resilience strategies that

improve safety and performance• Strategy and vulnerability/opportunity is the

most obvious pairing• Most difficult aspect of RMF is there is not yet

a developed taxonomy to guide observations• Focused on the team level at the moment

1. What is it? A framework to help identify resilience strategies in practice

2. What is it for? To help recognise, value, protect and share resilience practice

3. Where are we headed? Further studies to document resilience practice, so comparisons can be made within and across contexts so resilience can be fostered

Acknowledgements• Dr Jonathan Back and Prof Ann Blandford• Dr Astrid Mayer, Michael Hildebrandt and

Helena Broberg• All participants that took part in these studies• EPSRC

Thank you!

Questions

Dominic Furniss - d.furniss@ucl.ac.uk