Resilient Health Care, Volume 2 by Robert L. Wears Erik Hollnagel & Jeffrey Braithwaite

Resilient Health Care, Volume 2 by Robert L. Wears Erik Hollnagel & Jeffrey Braithwaite

Author:Robert L. Wears, Erik Hollnagel & Jeffrey Braithwaite
Language: eng
Format: epub
Publisher: Ashgate Publishing Limited
Published: 2015-12-09T16:00:00+00:00


Regulating CfM to Manage the Risk of Adaptive Breakdown

Units regulate their CfM in the face of changing external demands and pressures from interdependent units and echelons. If CfM becomes too low—if risk of saturation becomes too high—that unit becomes too brittle and risks a collapse in performance. Risk of saturating CfM is a candidate operational definition of brittleness (Woods, in preparation).

The Stephens et al. (2011) study shows these processes in action. Should patient load on the ED increase, it risks falling behind the pace of these new demands (Cook and Rasmussen, 2005). This is the basic adaptive system breakdown of decompensation (Woods and Branlat, 2011a) where the unit exhausts its capacity to adapt—CfM—as the unit falls behind the pace of incoming demands. In this pattern, breakdown occurs when challenges grow and cascade faster than responses can be decided on and deployed to effect.

Units are aware, at least implicitly, of the risk of the adaptive system breakdown of decompensation. We know this because we can observe, as in this study, units engage in locally adaptive responses to reduce the risk of exhausting their CfM given their appraisal of upcoming or potential events, demands, and challenges. As described above, the study of patient boarding found hospital units making many different adaptations to regulate their CfM and reduce the risk of decompensation for that unit.

The second basic adaptive system breakdown is working at cross purposes, which addresses the ability to coordinate different units at the same or different echelons in the face of goal and resource conflicts (Brown, 2005; Woods and Branlat, 2011a). Each unit works hard to achieve local goals as defined for their scope of responsibility. But the adaptations made to achieve their goals turn out to make it more difficult for other related units to meet the responsibilities of their roles—the adaptations of one unit also squeezes or constricts the CfM (and the ability to manage CfM) of other interdependent units. As a result of the mis-coordination between the units, each can be responding in ways that reduce their risk of exhausting their CfM, while at the same time increasing the risk that another interdependent unit saturates their CfM and triggers a performance collapse. From a more global perspective, the collapse of either unit, as interdependent, undermines the capacity of the system defined more broadly to meet global or long-term goals. One unit adapting to defend their own CfM in ways that constrict other units ability to manage their CfM risks outcomes that are poor for both (in the case studied maximizes benefits for patients). Thus, this risk can be described as behavior that is locally adaptive, but globally maladaptive (Woods and Branlat, 2011a). The Stephens et al. (2011) study revealed exactly this kind of locally adaptive, but globally maladaptive behavior across the interdependent units for the cases of defensive adaptations. The defensive adaptations helped one unit at the expense of other units so that the joint impact could inadvertently increase the risk of long length of stays (LOS) for patients (undermining the global goal of patient-centered care).



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