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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