Resilience Engineering: A More Positive Approach to Patient Safety

By Sheila J. Bosch

Most often in healthcare facility planning and design, patient safety efforts are focused on identifying adverse events that have occurred and trying to improve the environment or processes that contributed to those events. But, rather than exclusively examining what went wrong (known as Safety I), perhaps the focus should be more on ensuring that things go right (Safety 2). This proactive, more positive approach is rooted in resilience engineering. Although not a new concept, the application of resilience engineering in healthcare design may result in safer, more innovative facilities. Resilience refers to how individuals, teams and organizations adjust to changes or disturbances in order to maintain operations under both expected and unexpected conditions. Planners and designers should consider how to apply the principles of resilience engineering, including responding to actual conditions, monitoring critical behaviors and events, anticipating that which is possible and learning from factual information.

For example, there is some evidence that medication errors may be reduced if medications and patient wristbands are bar coded, then scanned at the patient bedside prior to administering medications. From a planning perspective, this system is intended to force nurses to dispense medications bedside. However, sometimes nurses will print duplicate patient wristbands and take several of them to the medication room simultaneously so they can scan the medications to patients faster, then deliver to the patients, thereby nullifying the safety measures of the bar-coded medication process. Failure to comply with the established protocol is perhaps not to be blamed on the nurses, but rather a process that is in direct conflict with efficiency principles. In such a situation, designers and administrators would do well to respond to the actual, which is, a situation that demands a more practical method for medication dispensing.

The new Porter Regional Hospital in Valparaiso, Ind., is an excellent example of using resilience engineering to both monitor the critical and anticipate the possible. The layout of departments and rooms minimizes the steps to services, while aiming to increase the speed of care, facilitate more private treatments and consultations, and improve patient outcomes. In the old facility, it was more than 100 yards from the emergency department to the nearest radiology room. The new facility has radiology across the hall from the ED. Reducing the travel distance from 100 yards to eight feet saves minutes; in the cases of trauma, stroke and chest pain patients, minutes may save lives. By addressing a critical need and anticipating the possible hazards of their previous layout, Porter proactively solved a problem with good design.

Miami Valley Hospital South in Centerville, Ohio, spent a great deal of time learning from the factual by studying existing care processes, and identifying and implementing improvement opportunities for their new facility. Processes that support staff in sustaining key operations — even in the face of unexpected challenges — were introduced. As an example, decentralized patient floors with wide corridors and an abundance of caregiver stations and supply alcoves allow nurses and physicians to work together in close proximity to patients, enabling better communication and perhaps improving patient safety.

It’s no secret that resources are already stretched and time to evaluate processes is limited in a healthcare setting. But when assessing existing versus optimized processes, it is imperative to try and identify the subtle things that could facilitate improvement. As Erik Hollnagel states in his paper A Tale of Two Safeties, “It must be legitimate within the organizational culture to allocate resources — especially time — to reflect, to share experiences and to learn. If that is not the case, then how can anything ever improve?”

Designers, administrators and healthcare staff, all working proactively to address the four cardinal activities of resilience engineering, can achieve tremendous results.

Sheila J. Bosch, Ph.D., LEED AP, EDAC, is director of research at Gresham, Smith and Partners, serving as a firm-wide resource for planners and designers as they apply research evidence to enhance quality, safety and efficiency in healthcare settings.

Photo caption:
At Miami Valley Hospital South in Ohio, each patient floor has six caregiver stations and six supply alcoves, so nurses and physicians are always in close proximity to the patient rooms. Alcoves can be used for the needs of the department, storing things like Pyxis machines, dietary supplies, crash carts and other items.