Resilient Health Care: Muddling Through with Purpose

I: OpeningsIntroduction: How We Got HereThe Necessity of Muddling ThroughThe Historical ContextLogic and RationalismHomo EconomicusThe Practical ChallengesMuddling Through During a CrisisReferencesII: Case Studies of MuddlingManaging Complexity and Manifestations of Resilience in Operating Theatres: Sensemaking and Purposive Muddling Among Scheduling NursesResearch Design and MethodsResearch SettingResearch DesignData Analysis FrameworkResultsIn the Eye of the StormVisibility of Processes, Outcomes and Consequences of ChangeOrganising with SlackDiversity in Decision-MakingWork-as-Done and Work-as-ImaginedDiscussionConclusionReferencesRe-designing the Blood Transfusion Procedure in Operating Theatres: Aligning Work-as-Imagined and Work-as-DoneAn Incident Report and Work-as-Imagined – Work-as-doneAn Incident ReportWork-as-Imagined (Hospital-Wide Rules)Work-as-Done (Operating Theatres Everyday Practice)Muddling Through Decision and Its ReasonsBlood Transfusion PolicyUnintended FeedbackReconciling the GapRound Table DiscussionPerception of the Present ProcedureCreating Consensus Through Shared ValueQuestionnaire SurveysEducational VisitDiscussionReferencesDynamic Performance of Emergency Medical Teams as Seen in Responses to Unexpected Clinical EventsCase Study: Response to Multiple CasualtiesContact from the Ambulance Dispatch CentrePreparation for Receiving Casualties (Staff, Place and Equipment)Unexpected PatientReceiving the CasualtiesFrom Initial Treatment to Definitive CareFlexible Team Response to the Unexpected Clinical EventOrganisms that Change Their Shape Adjusting to the SituationCollapsible and Scalable Medical Teams: Medical Teams that Change ‘Shape’ According to the SituationRole of the LeaderLearning OrganisationInterpretationConclusionReferencesFrom Mortality and Morbidity Conference to Quality Assessment Meeting: Step-by-Step Improving Team ResilienceThe Traditional Mortality and Morbidity ConferenceThe Need for a Novel Format for Mortality and Morbidity ConferencesThe Quality Assessment MeetingThe QAM Meeting to Address the Potentials for Resilient PerformanceFuture ImprovementsReferencesImages of Work-as-ImaginedIntroductionMethodsFindingsExternal-Formal Work-as-ImaginedExternal-Informal Sources of Work-as-ImaginedInternal Sources of Work-as-ImaginedDiscussionConclusionReferencesIII: The Functional Resonance Analysis Method (FRAM) as a Gateway into Muddling with a PurposeExperiences with FRAM in Dutch Hospitals: Muddling Through with ModelsApplications of FRAMWhere to Start?Modelling Work-as-Imagined and Work-as-DoneStakeholder Meetings and Improvement InitiativesUsing FRAM to Reveal Muddling Through-Like BehaviourMuddling Through with WorkaroundsMuddling Through Using Personal AidsMuddling Through with Unclear or Unpractical RolesUsability of FRAMSuggested Framework for FRAM Model InterpretationStrengths of FRAMChallenges of FRAMConclusion and Future PerspectivesReferencesModelling a Typical Patient Journey Through the Geriatric Evaluation and Management Ward to Better Understand Discharge Planning ProcessesMethodFunctional Resonance Analysis Method (FRAM)Step 0 The Purpose and Scope of the AnalysisStep 1 Describe Potential and Actual Performance VariabilityStep 2 Describe Potential and Actual Performance VariabilityStep 3 Aggregation of Performance Variability and Step 4 Propose Ways to Control VariabilityResultsDescribing the ClustersCluster 1: To Prepare the Preliminary Discharge PlanTo Refer the PatientTo IntakeTo Admit the PatientTo Do Initial AssessmentTo Provide Allied Health Service/To Provide Nursing Care/To Do Medical Ward Round/ReviewTo Do Ongoing AssessmentTo Identify the Discharge PlanCluster 2: The Resources Required for the Discharge Plan and Patient Supports Post-DischargeTo Hold Case ReviewTo Hold Family MeetingTo HuddleTo Hold Case ConferenceTo Hold Feedback MeetingCluster 3: Major Influences on the Discharge Plan and the Supports for the Patient Post DischargeTo Engage the PatientTo Prescribe the Formal SupportsTo Follow the Model of CareCluster 4: Readying the Patient for DischargeTo Organise Day of Discharge ResourcesTo Confirm Clinical/Functional StabilityTo Notify Staff that Discharge is in ProgressTo Complete Discharge PaperworkTo Arrange TransportTo Ready the Patient for DischargeCluster 5: Discharging the Patient from the WardTo Discharge the Patient from the WardTo Transit to DestinationRisk of Functional Resonance and Dampening the Performance VariabilityMissed ReferralsMissing Information from IntakeDelayed Assessments to Enable Formulation of the Discharge PlanDelayed Notification of Pending DischargeKey Features that Dampen Uncontrolled Performance VariabilityModel of CareEngagement with the PatientDaily Communication and Sharing of InformationDiscussionPractical ImplicationsResearch ImplicationsLimitationsReferencesMuddling Through in the Intensive Care Unit: A FRAM Analysis of Intravenous Infusion ManagementFRAMExample: Intravenous Medication OrderingConclusionAcknowledgementsReferencesMuddling Through the Built Environment to Preserve Patient Safety and Well-BeingBuilt Environment in Intensive Care UnitsResearch MethodScenarioData CollectionData AnalysisResultsDiscussionConclusionReferencesIV: Muddling with Application: In and Around HospitalsSimulation to Surface Adaptive CapacityWhere In Situ Simulation Fits inAdaptations, Pandemics and SimulationOn Systems and MicrosystemsDiscussion and ConclusionReferencesTowards Safety-II in Hospital Care Using the Available Safety-I Environment: Patient-Level Linkage of Currently Available Hospital DataCurrent Use of Patient Safety DataFocussing on the NegativeReal-World Complexity and Relations between Events Remain ObscuredConnecting the Data SilosMaterial and MethodsRevealing the PositiveTarget GroupsRevealing Resilient Behaviour and Muddling at the Sharp EndConclusionReferencesPeer-to-Peer Information Sharing for a High-Quality, Autonomous and Efficient Health Care SystemGaps in Care Goals between Health Care Providers and PatientsIncreasing Recognition of Patient Engagement and Patient-Centred CareProblems in Decision-Making on Dialysis ModalityProblems in Self-Management of Life-Long IllnessA World Café Style-Workshop with PD PatientsSetting and Development of the PD CaféThe Programme and Methods of the PD CaféEffects of Peer-to-Peer InteractionsDiscussionConclusionReferences‘Muddling Through’ Care Transitions: The Role of Patients and Their Families‘The Science of Muddling Through’ – What Can this Add to Our Understanding of Transitional Care?Successive Limited Comparisons Limit the Values to Be OptimisedSame Values, Different Interpretation?Evaluating Success Is Not ‘Value-Neutral’Incrementalism Shapes Behaviour within ServicesMuddling Through Transition – The Staff PerspectiveBeing Muddled Through Transition – The Patients’ PerspectivePatients' Responsibilities in Hospital - A Quadruple-Edged SwordSelf-Medication in Hospital – Whose Risk Is It Anyway?The Surprise of DischargeThe Resilience of Patients and FamiliesA Transitional Muddle – Combining these PerspectivesCan We Systematically Support Patients and Families to Improve the Resilience of Transitional Care?The ‘Your Care Needs You’ InterventionConclusionAcknowledgementsReferencesV: ClosureConclusion
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