title: Implementing resilience engineering for healthcare quality improvement using the CARE model: a feasibility study protocol.
abstract: BACKGROUND
  Resilience engineering (RE) is an emerging perspective on safety in complex adaptive systems that emphasises how outcomes emerge from the complexity of the clinical environment. Complexity creates the need for flexible adaptation to achieve outcomes. RE focuses on understanding the nature of adaptations, learning from success and increasing adaptive capacity. Although the philosophy is clear, progress in applying the ideas to quality improvement has been slow. The aim of this study is to test the feasibility of translating RE concepts into practical methods to improve quality by designing, implementing and evaluating interventions based on RE theory. The CARE model operationalises the key concepts and their relationships to guide the empirical investigation.
  
  
  METHODS
  The settings are the Emergency Department and the Older Person's Unit in a large London teaching hospital. Phases 1 and 2 of our work, leading to the development of interventions to improve the quality of care, are described in this paper. Ethical approval has been granted for these phases. Phase 1 will use ethnographic methods, including observation of work practices and interviews with staff, to understand adaptations and outcomes. The findings will be used to collaboratively design, with clinical staff in interactive design workshops, interventions to improve the quality of care. The evaluation phase will be designed and submitted for ethical approval when the outcomes of phases 1 and 2 are known.
  
  
  CONCLUSIONS
  Study outcomes will be knowledge about the feasibility of applying RE to improve quality, the development of RE theory and a validated model of resilience in clinical work which can be used to guide other applications. Tools, methods and practical guidance for practitioners will also be produced, as well as specific knowledge of the potential effectiveness of the implemented interventions in emergency and older people's care. Further studies to test the application of RE at a larger scale will be required, including studies of other healthcare settings, organisational contexts and different interventions.
authors.affiliation: Florence Nightingale Faculty of Nursing and Midwifery, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA UK.
authors.forename: J E
authors.initials: JE
authors.lastname: Anderson
authors.affiliation: Dental School, School of Medicine, University of Glasgow, Glasgow, UK.
authors.forename: A J
authors.initials: AJ
authors.lastname: Ross
authors.affiliation: Florence Nightingale Faculty of Nursing and Midwifery, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA UK.
authors.forename: J
authors.initials: J
authors.lastname: Back
authors.affiliation: Florence Nightingale Faculty of Nursing and Midwifery, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA UK.
authors.forename: M
authors.initials: M
authors.lastname: Duncan
authors.affiliation: Guy's and St. Thomas' NHS Foundation Trust, London, UK.
authors.forename: P
authors.initials: P
authors.lastname: Snell
authors.affiliation: BMJ Learning, BMJ, London, UK.
authors.forename: K
authors.initials: K
authors.lastname: Walsh
authors.affiliation: Simulation and Interactive Learning (SaIL) Centre, St Thomas' Hospital, King's Health Partners, London, UK.
authors.forename: P
authors.initials: P
authors.lastname: Jaye
keywords: Mixed methods; Organisational resilience; Patient safety; Quality improvement; Quality of care; Resilience engineering; Resilient healthcare