Infusing Healthcare with Resilience

Resilience engineering strives to build the adaptive capacity of systems that is essential to continue operations in the face of substantial challenges. The healthcare enterprise provides a compelling opportunity to consider resilience as a desirable trait of systems. Clinicians, from physicians to nurses and technicians, are a source of resilience and develop and rely on artifacts from status boards to information systems and equipment to perform cognitive work. While information technology (IT) systems have been promoted as a means to improve patient safety, current information systems and equipment systems are brittle and erode resilience instead of contributing to it. Based on a five-year study funded by the Agency for Healthcare Research and Quality, we present a concept for an infusion device interface that would contribute to resilience. Resilience and its engineering The ability of any system to adapt to a changing environment relies on a deep understanding of the system, what it does, and what it cannot do. Systems that are poorly configured for change are said to be brittle (Sarter, Woods and Billings, 1997). By contrast, systems that are designed to be adaptable and to withstand challenges and return to normal with minimal decrement in performance are said to be resilient (Hollnagel, Woods, and Leveson, 2006). Resilience can be seen in action because it is made visible by the way safety and risk information are used. Resilience is more than a simple set of resources because it involves adaptation to varying demands and threats that are brought on by the continuing negotiation among competing economic and workload pressures (Nemeth, 2009). As Figure 1 shows, these can pressure an organization’s operating point (represented by the encircled dot). Depending on the circumstances, the operating point can be caused to shift toward the boundary of acceptable performance (Cook and Rasmussen, 2005) and prospective failure. Resilience is an active process that implicitly draws on how an organization or society can organize itself and promises to replace traditional notions of risk assessment by shifting attention to a prospective view that anticipates future events that may challenge system performance. The ability to foresee and adapt to changing conditions increases the system’s ability to survive despite Figure 1. Influences on a system’s operating point (Cook and Rasmussen, 2005) variations in its environment. Adaptation and restructuring make it possible for an organization to meet varying, even unusual, demands. Resilience engineering (RE) focuses on the ability of an organization to cope with, and recover from, unexpected developments. Rather than a focus on a system’s productive capacity, RE can be used to assess and enhance the ability of an organization to adapt in order to meet challenges. With roots in complexity study (Carlson and Doyle, 2002) and cognitive systems engineering (Hollnagel and Woods, 2005), RE seeks to create and maintain systems that can cope with and adapt to complex, dynamic, and changing environments. RE acknowledges the inability to specify all possible threats to a system and system responses. Instead, it provides methods and tools to manage safety and productivity. This paper addresses issues related to healthcare information and communications technology (ICT) at the system level. It also shows how the most widely-used IT-controlled device, the infusion pump, can be developed to support operators who must cope with a complex, fluid, uncertain work domain.