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Über dieses Buch

Resilience Engineering (RE) studies have successfully identified and described many instances of resilient performance in high hazard sectors as well as in the far more frequent cases where people and organisations cope with the uncertainties of daily operations. Since RE was first described in 2006, a steady accumulation of insights and efforts have provided the basis for practical tools and methods. This development has been documented by a series of texts in the Resilience Engineering Perspectives series as well as by a growing number of papers and reports.

This book encapsulates the essential practical lessons learned from the use of Resilience Engineering (RE) for over ten years. The main contents are a series of chapters written by those who have been instrumental in these applications. To increase the value for the reader, each chapter will include: rationale for the overall approach; data sought and reason(s) for choosing; data sources used, data analyses performed, and how recommendations were made and turned into practice.

Serving as a reference for practitioners who want to analyse, support, and manage resilient performance, this book also advances research into RE by inquiring why work goes well in unpredictable environments, to improve work performance, or compensate for deficiencies.

Inhaltsverzeichnis

Frontmatter

From Resilience Engineering to Resilient Performance

Abstract
Looking back at how resilience engineering made its entry onto the safety arena in 2004, resilience was initially seen as a substitute, and part extension, of safety, hence as something that could be engineered or managed. In the years since then it has become clear that how systems perform, and especially whether the performance is resilient, is more important than whether they are resilient. This chapter identifies the main conceptual and practical developments from 2004 until today.
Erik Hollnagel, Christopher P. Nemeth

Development of Resilience Engineering on Worksites

Abstract
Many worksite managers are troubled by the aspect of human error on workers. Though they have made various measures such as preparing manuals with guidelines and compelling workers diligently to follow the manuals, it has been impossible to eliminate human error. Field managers are vaguely aware of limitations of those measures that have been previously implemented. Therefore, there are significant expectations from Resilience Engineering, or Safety-II, as a new approach to tackle human error prevention. However, the emphasis that on-site staff ought to be flexible in adapting to changing worksite conditions can also lead to problems. Therefore, in this chapter,  an easy-to-understand scenario will be presented to explain an overview of safety activities, including resilience that must be undertaken at worksite. Furthermore, the story is intended to draw attention to and emphasise certain key management ideas for resiliency.
Akinori Komatsubara

Fatigue Risk Management System as a Practical Approach to Improve Resilience in 24/7 Operations

Abstract
A growing body of literature indicates that schedules involving extended shifts, night work or other forms of atypical working hours substantially increase workers’ fatigue (Chellappa et al., 2019; Doghramji et al., 2018; Czeisler, 2015). These schedules are associated with reduced work performance (Caruso, 2014) and higher risk of errors and accidents (Salminen, 2016; Wirtz, 2010). Despite alarming figures, extended shifts and night work are becoming more common in our so-called 24/7 society. It is estimated that approximately 25% of American workers operate shifts that are not during the daytime (NHLBI, 2005), and nearly 30% work 10 h or more each day (NSF, 2008).
Pierre Bérastégui, Anne-Sophie Nyssen

Using the Resilience Assessment Grid to Analyse and Improve Organisational Resilience of a Hospital Ward

Abstract
Helping organisations to perform in a resilient manner is an emerging area of research in healthcare, but despite philosophical development there remains a lack of practical tools that can be used by practitioners. Tools and methods for analysing resilient performance are needed to inform organisational improvement. This chapter describes a new method for analysing resilience in hospital systems based on the Resilience Assessment Grid (RAG). The RAG is a tool for analysing the four resilience potentials (Hollnagel, 2018) proposed to underpin resilient system performance: anticipating, monitoring, responding, and learning (Hollnagel, 2010). Its purpose is to assist users to analyse their own system and diagnose areas of weakness by answering a series of questions about the four resilience potentials. However, the original questions proposed in the RAG were high level and abstract. They were designed to be adapted to the local context in which it was to be applied and used in a survey administered to staff, but there was little guidance provided for adapting the questions to the context. Previous research has used different methods for developing contextual RAG survey items, but these are either too close to the original theoretical items and not very clear for healthcare professionals (Hunte, 2016; Engvall et al., 2017) or include conceptual additions which are not developed sufficiently for understanding resilient performance (Van der Beek & Schraagen, 2015; Rigaud et al., 2015).
Matthew Alders, Anne Marie Rafferty, Janet E. Anderson

Learning from Everyday Work: Making Organisations Safer by Supporting Staff in Sharing Lessons About Their Everyday Trade-offs and Adaptations

Abstract
There is broad agreement that organisational learning in healthcare is a key mechanism for improving patient safety, but at the same time frustrations with existing approaches based predominantly on learning from incidents are running high, fuelled by lack of progress and staff disengagement with learning processes. The argument in this chapter is that the struggles with organisational learning in healthcare are, at least in part, due to the narrow way in which learning has been cast as learning from incidents, without proper consideration of how healthcare professionals actually deliver care, and how the learning processes need to be embedded and supported within an organisation. An approach to learning from everyday work based on Resilience Engineering thinking is outlined, and its application in a multi-site study is described. The chapter concludes that healthcare organisations should adopt the Resilience Engineering perspective to create a more positive, inclusive and ultimately more effective learning environment for improving patient safety.
Mark Sujan

Reflections on the Experience of Introducing a New Learning Tool in Hospital Settings

Abstract
Event reporting systems are widely prevalent across healthcare organizations and are used as tools to learn about a variety of negative outcomes and near misses. As artifacts of the traditional approach to safety, their scope is mostly limited to learning how things go wrong based on specific episodes or incidents. In order to expand the learning focus to include descriptions of everyday contexts characterized by variability and adaptation, the Resilience Engineering Tool to Improve Patient Safety (RETIPS) was developed. RETIPS was implemented on a pilot basis focusing on anesthesia residents at a large multispecialty hospital. Participants self-reported lived experiences of workflows and adaptations in ‘everyday’ situations, regardless of whether these narratives were associated with any incidents. The chapter reflects on the authors’ experience of developing the tool and implementing at the hospital, and offers insights for transforming organizational learning from traditional approaches toward more proactive learning of how things work in daily practice.
Sudeep Hegde, Cullen D. Jackson

Resilient Performance in Aviation

Abstract
Resilience is 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” (Woods & Hollnagel, 2006, p. xxxvi). If there was ever an industry that has demonstrated this ability, it is the aviation industry. The industry has continually demonstrated the ability to adjust and sustain operations after unexpected events, and has improved both reliability and safety in the midst of increasing complexity of the aircraft, economic challenges, and aviation systems that are dependent on a range of different organizations to succeed (Høyland & Aase, 2008). It has been proposed that resilience is a characteristic of system performance, not the system itself (Hollnagel, 2011), and therefore it is fitting to examine the aspects of aviation that enable it to demonstrate resilient performance. This chapter presents a discussion of resilient performance in aviation, including what resilient performance looks like in aviation, how it is currently achieved, and methods to further advance resilient performance in the future.
Meredith Carroll, Shem Malmquist

Assessing the Impacts of Ship Automation Using the Functional Resonance Analysis Method

Abstract
The maritime industry is experiencing a steady evolution towards a concept of fully automated ship operation. The implementation and use of automated systems have been debated for many decades, and yet substantial issues remain regarding its achievements in terms of improved safety and efficiency (Wiener & Curry, 1980). The assessment of potential impacts (i.e. risk assessment) emerging from the introduction of automation remains a key challenge. The integration and streamlining of operations significantly increase complexity, and the transformations that are introduced tend to produce unforeseen side effects, often with serious safety consequences (Dekker et al., 2011).
Pedro Ferreira, Gesa Praetorius

A Methodological Framework for Assessing and Improving the Capacity to Respond to the Diversity of Situations That May Arise

Abstract
The capacity to respond to the diversity of situations that may arise is one of the cornerstones of safety management’s Resilience Engineering perspective. This chapter focuses on the description of a framework aiming to collect and analyze data for supporting its assessment and the proposal of corrective actions. Resilience Engineering’s theoretical background endorses the definition of performance indicators. Individual and collective interviews help the identification of factors to be corrected and others to be preserved.
Eric Rigaud

Addressing Structural Secrecy as a Way of Nurturing Resilient Performance

Abstract
Structural secrecy refers to a systematic undermining of attempts to know and interpret situations in organisations, which significantly challenges their abilities to perform resiliently. In this chapter, we briefly share some insights drawn from a collaboration with the municipality of Malmö, Sweden, for a period of more than three years that has provided knowledge about the needs and constraints to better addressing challenges related to structural secrecy. To deal with this problem, it is essential to find ways of sharing insights about the criticality and interconnections between organisational units. The chapter outlines a method implemented in the departments in Malmö municipality used for compiling and spreading such information within the organisation as a means to become better equipped for managing both daily tasks and surprises. By contributing to an alignment of diverging views on “work as done” versus “work as imagined” this type of effort lays the groundwork for nurturing an ability to perform resiliently in suddenly emerging situations that are outside the organisation’s normal operations.
Alexander Cedergren, Henrik Hassel

The Second Step: Surprise Is Inevitable. Now What?

Abstract
The ontological underpinnings of resilience engineering focus on the experience of surprise as an inescapable component of existence in the complex adaptive universe (Woods & Hollnagel, 2006). The resource limitations of all systems (especially cognitive systems) force the units of those systems (agents) to create and rely on models of the world. These models are necessary and necessarily incomplete – they are simplifications of the world on which they are based. Because they are simplifications, there will be inaccuracies in their predictive power; this will lead the agents – users of the models – to experience surprise (Woods & Hollnagel, 2006). Although past attempts to produce thorough and exhaustive lists of all potential outcomes (robustness exercises) have produced significant results in controlled settings or where large recourse endowments are available, the benefits of those techniques are architecturally resource-limited by the mitigative mechanisms which field the creativity of the practitioners devising the scenarios. Such attempts to “outthink” the universe by defining each potential specific instance are necessarily limited in their ultimate operational effectiveness. Consequently, capacities to deal with the inevitable surprises must be developed and maintained when and where the work is done.
Beth Lay, Asher Balkin

Quo Vadis?

Abstract
In the end, we must keep in mind that it is more important to ask the right questions than simply to hunt for answers to the questions that we – and others – habitually ask.
Erik Hollnagel, Christopher P. Nemeth
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