Resilient health care, Vol. 2 (2015)

Copyright © Erik Hollnagel 2020

All Rights Reserved.

The chief motive of all human actions is the desire to avoid anxiety.

Ibn Hazm (994-1064)

Wears, R. L., Hollnagel, E. & Braithwaite, J. (Eds.) (2015). Resilient health care, Volume 2: The resilience of everyday clinical work. Farnham, UK: Ashgate.


This book is the second volume focusing on the application of resilience engineering thinking to health care, or simply resilient health care. The first book, Resilient Health Care (Hollnagel, Braithwaite & Wears, 2013) documented the thinking of leading experts in health care, patient safety, and resilience engineering on the intersection of these three main areas. Patient safety became publicly recognised as a growing concern with the release of the Institute of Medicine (IOM) report To Err is Human (Kohn, Corrigan and Donaldson, 2000), although the problem obviously had been recognised before that (e.g., Cook, Woods and Miller, 1998). Resilience engineering emerged around the same time (Woods, 2000), and a book of the same name was published in 2006 (Hollnagel, Woods and Leveson, 2006), mainly as an outcome of the first symposium on the topic that was held in 2004. Resilience engineering has since then received widespread recognition in a variety of industrial domains, and the developments have been amply documented in books and papers. Resilient health care is the first of hopefully many such specialised applications.

Resilient health care can be defined as the ability of the health care system (a clinic, a ward, a hospital, a county) to adjust its functioning prior to, during, or following events (changes, disturbances, and opportunities), and thereby sustain required operations under both expected and unexpected conditions. This definition echoes WHO’s statement, drawn from a public health rather than a patient safety perspective, that “Health is more than the absence of disease”. It underlines that patient safety is more than the absence of accidents and incidents. In order to enable a health care system to perform in a resilient manner it is therefore necessary to study and understand how health systems work, and not just how they recover from failures and other calamities. It is necessary to put the focus on how health care systems succeed and stop perpetuating the myopic view of how they fail. This realisation has been expressed by juxtaposing two views on safety, Safety-I and Safety-II – not only in resilient health care but in safety thinking in general (Hollnagel, 2014). While Safety-I is defined by the (relative) absence of adverse events (accidents, incidents), Safety-II is defined as the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes (in other words, everyday activities) is as high as possible. Where Safety-I focuses on what goes wrong (protective safety), Safety-II focuses on what goes right (productive safety). The purpose of safety management is therefore not so much to prevent accidents as to provide and maintain the ability to succeed under varying conditions.

The Resilient Health Care book mixed a number of theoretical perspectives (e.g., socio-cultural criticism, complex adaptive systems, quality management, mindfulness, and of course resilience engineering) with a number of empirical studies (e.g., reorganisation in intensive care units, robotic surgery, standardisation of practice, ‘just in time’ information, and patient empowerment) to provide an initial map of the territory, so to speak. One thing that spoke very clearly from this work, was that everyday performance is characterised by the ways in which people adjust or modify what they do in order to accomplish their work. This is furthermore not something that is peculiar to the health care domain, but a rather a general characteristic of human performance under all conditions, regardless of type of work and domain.

The current volume takes a closer look at this, hence its title The Resilience of Everyday Clinical Work or RECW for short. The title emphasises that the focus for health care improvements – with regard to safety as well as with regard to quality and the more recent paradigm, implementation science – must be everyday clinical work. (Of course, the same kind of argument can be applied to any type of work.) In other words, it is necessary to take a closer look at work as it takes place in everyday working situations. The basis for patient safety or health care quality cannot and should not be the cases where things go wrong, either in the sense that an accident or incident occurs, or in the sense that formal quality criteria are not met. Nor should the basis be the cases where things go exceptionally well, the situations that we loosely call successes, but which we rarely make an effort to understand. Rather than looking at either (or both) tails of a normal distribution of outcomes, we should look at the broad area in the middle, at the things that happen frequently or always, in the daily activities of the everyday clinical work that just functions and unfolds regularly, as it should.

When something is unexpected, as when something goes wrong – and more rarely as when something goes exceptionally right – it attracts our attention. Humans as individuals seem to be sensitised to notice the unexpected. Once alerted, our societies and organisations, and indeed our cultures, have a natural and irresistible reaction to study those phenomena. But we should realise, that whenever something goes wrong it rarely, if ever, happens for the first time. Whatever happens, whatever is done, has happened or has been done many times before and will in all likelihood be done again many times in the future. It has been done many times before and it will be done many times again for the simple reason that it works. Understanding how things are done when nothing goes wrong – the daily routines, the habitual solutions to the myriad of small problems that constantly stand in our way – is therefore the precondition for understanding how things can possibly fail.

Looking at everyday clinical work is merely a first step on the road to resilient health care, but it is a necessary one. Figuratively speaking, taking the first step down this path towards resilient health care means that we stop walking down the path of failure studies. We still strive to reach the same goal, namely a health care system that is effective and where as many things as possible go right, but by taking a new path we may get there earlier and perhaps with less effort.