Borrowing concepts from industry and the military, Texas Children's addresses rapid changes to improve patient outcomes.
"COVID-19 has dramatically challenged us to use these RE principles as we have had to respond to rapid changes in CDC guidelines, testing and PPE availability, disease burden and exposure management."
An agile, flexible workforce has always been essential in health care—and the past several months have underscored the importance of adaptation to rapidly shifting conditions. It's in that vein that Texas Children's Hospital looked to build more resiliency into its workflows.
"People have been doing quality and safety work for quite some time, but what's next?" says Eric Williams, M.D., M.S., M.M.M., FAAP, FCCM, system chief quality officer, Texas Children's Hospital in Houston. "That's the fundamental piece of it—for us to be successful in this rapidly changing world, we must learn to move quickly as an organization in response to change."
Resilience engineering driving culture shift
Williams and his team have embraced resilience engineering (RE) to meet those challenges. RE has been defined as "the intrinsic ability of a system to adjust its functioning prior to, during or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions." While it's rooted in industry, the concepts translate well to a health care setting.
Among those concepts is recognizing that defined processes—while often necessary—are inherently imperfect; humans must adapt their performance to succeed, according to Williams. To that end, RE focuses on four primary tenets: the ability to respond, monitor, learn and anticipate.
"Teams that are better able to adapt could move quickly to solve quality and safety-related issues," Williams says. "It's about truly understanding human error, how that leads to better causal analysis and changing the question from 'who failed?' to 'what failed?'—it's a culture shift."
Custom-made curriculum for "hand-picked champions"
To foster this culture shift at Texas Children's, Williams and his team pored over RE and Safety-II literature to develop a curriculum. The result was a four-day course of RE theory mixed with simulation exercises. Williams enlisted the McChrystal Group—a management consulting firm founded by former military leaders—to assist with the latter.
In assembling the initial study group last year, Williams' team selected "hand-picked champions" from across the organization—staff members identified not only as early adopters who were likely to embrace the concepts but also as "influencers" who would spread them back throughout their teams.
"It's a culture change; it starts one person at a time, and you have to scale it," Williams says.
RE course spurs a-ha moments
The course was eye-opening for both instructors and students. Among the a-ha moments, according to Williams:
- Information sharing. Some of the simulation exercises mimicked military work and demonstrated the natural tendency of large organizations to be information silos; information is often reported up the organization and not across. "It changes the mantra to 'who would benefit from knowing what I know?' as opposed to 'this information defines me,'" Williams says.
- Hindsight bias. Errors can appear obvious after the fact, and cause and effect may be mistakenly assumed. Appreciating hindsight bias can better inform training after errors occur.
- Regulations. When policies and processes are established that don't sync with how work is performed, the organization loses resiliency and patient outcomes can suffer.
Investing in education critical to success
Williams says feedback from the initial RE curriculum group has been positive, and they're now in Plan, Do, Study, Act (PDSA) cycles to assess how the concepts are being practiced in day-to-day work. Meanwhile, Williams and his team are assembling additional cohort groups for the program.
Key to the entire process of this paradigm shift, according to Williams, is learning. It can be very challenging to allocate the time and resources necessary to read the literature, properly learn the concepts and determine the tools available to effect change.
"Most people are busy reacting to the bombs going off in their organization," Williams says. "They're unable to move to a more proactive stance where they're anticipating the bombs before they go off."