By Mark Sujan, Laura Pickup and Peter McCulloch on behalf of the RESPOND project team Nuffield Department of Surgical Sciences, University of Oxford
Resilience Engineering and its healthcare-specific incarnation Resilient Health Care are coming of age, with the first Resilience Engineering book published almost 15 years ago and the Resilient Health Care counterpart 8 years ago. During this period, the focus has been on the development of concepts and methods, aimed at making visible mechanisms of resilience or describing resilience characteristics based on qualitative studies using observations, interviews and focus groups. It is no surprise, therefore, that in healthcare the majority of Resilience Engineering research tried to contribute to and extend our understanding of everyday clinical work and the many adaptations that clinicians have to make in order to deliver safe care in complex clinical environments.
However, it is important that these insights are now complemented by a body of research that provides evidence about how interventions based on Resilience Engineering principles can make a difference in practice. This is particularly true for healthcare, where there is a strong tradition of evidence-based medicine, but it applies equally across different sectors.
The RESPOND study is a 5-year research project funded by the National Institute for Health Research in the UK, which aims to provide rigorous evidence of a set of Resilience Engineering interventions through a clinical trial. The topic of the research is the management of patients who deteriorate following emergency surgery. Prior research demonstrated that the rate of complications following surgery is roughly comparable across different organisations (around 1 in 4 patients), but that the rate of patient death following complications can be much lower (about half) in successful hospitals compared with lower-performing hospitals. This means that some hospitals are better at recognising when a patient deteriorates and at escalating their care accordingly.
The rate of mortality following a complication is an important quality indicator, and has been given a specific name – failure to rescue. Accordingly, much of the research has been occupied with identifying factors that contribute to failure to rescue, i.e. factors that lead to negative outcomes. Of course, another way of looking at this issue, and one familiar to those within the Resilience Engineering community, is to study how the management of deterioration usually succeeds.
In the RESPOND project we are using FRAM to analyse the management of the deteriorating patient from a Resilience Engineering perspective. We will identify a set of interventions that are aimed primarily at strengthening the resilience of the clinical system. After an initial pilot in a small number of organisations, the set of interventions will be evaluated in a cluster-randomised stepped-wedge trial involving up to 24 hospitals.
A stepped-wedge trial is a rigorous evaluation approach suitable for testing complex interventions. In the step wedge design, there is no (randomised) control group. Instead, all study sites (clusters) receive the intervention, but they are randomly allocated to one of a series of “steps”, which start the intervention at different times during the trial. The change caused by the intervention is measured by comparing outcome data from before and after intervention begins. The evaluation of Resilience Engineering interventions using accepted trial designs can help construct a more persuasive case for the benefit of Resilient Health Care, and can also be a model for other industries.
Further detail: https://fundingawards.nihr.ac.uk/award/NIHR200868
Funding acknowledgement: This project is funded by the National Institute for Health Research (NIHR) [PGfAR NIHR200868]. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
