Extemporaneous Adaptation to Evolving Complexity: A Case Study of Resilience in Healthcare

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This week we’re going over a case study by Shawna Perry, Robert Wears, and Brandon Anderson. They walk us through a small snapshot of an instance where resilience emerged at a hospital in ways that aren’t normally supported by the normal ways of working.

Extemporaneous Adaptation to Evolving Complexity: A Case Study of Resilience in Healthcare

This is a case study about an event that happened in a hospital that demonstrates resilience in healthcare. Even though I tend to focus on software people, I still think there’s a lot that we can learn here as much of the case study is about how everything works together.

It’s also interesting to me that this can’t really be said to be resilience engineering as none of this process was created to be this way and as we’ll see the processes in place may in fact have been subverted to allow things to be this way.

The case focuses on physicians from different specialties that had never worked together before, though they all work in the same hospital.

Some background that the authors give us that is helpful to understand why this case study is significant especially in this domain is because of the way healthcare works in the US.

It’s rare for doctors to do collaborative work with other doctors. The system as a whole of course has much interdependence across specialties, but when we zoom into the individual physician level we see that their operations are fairly self-contained. The authors tell us that this is somewhat of an attempt to minimize complexity.

But also because of a hierarchy that has some pretty rigid boundaries, assessment and treatment of a patient tends to happen sequentially. That is typically a patient will see one Dr. who will order some things and perhaps refer them to another doctor who will then practice their specialty.

This is also somewhat reinforced by billing practices in the US, in that often multiple physicians working on a case same time won’t be paid by insurance the same way as if they were working sequentially.

I think medicine has also been experiencing something that we have been beginning to and software, which is increased specialization. As medicine has become increasingly specialized doctors and other healthcare practitioners can have a harder time understanding other specialties and seeing chances for simultaneous, cooperative clinical work, even if it were encouraged.

Another thing that felt very familiar is that the authors cite a study that looked at how specialists think up diagnostic possibilities. They found that specials tend to generate more hypotheses from their own specialty for a given patient than they do others in further they estimate a higher probability of them being correct in their specialty than others.

The Case

In this case a pregnant women arrived at the ER with abdominal pain and chest pain that had been going on for the last day. As was protocol in the hospital, she was sent to the labor and delivery department for examination and fetal monitoring.

She was examined by the OB resident, but nothing was found. Later in the night though, her blood pressure become unstable while her pain worsened.

The OB attending then called his supervising Attending Dr, who then suggested it was a heart attack. The patient was then moved to an operating room for a c-section so that the stress on the patient would be lessened as would the danger to the fetus.

The Attending anesthesiologist though had concerns about sedating the patient as it was very high risk if the problem was in fact a heart attack. They suggested that a more definitive diagnosis be sought before moving forward.

As a result attempts were made to reach a cardiology resident, but they could not be found. The OB Attending then called the Emergency Department Attending and asked for help. The ED doctor recommended treating the patient as if they were having a heart attack and also tracked down the cardiology fellow and went to the OR. They looked over the information they had and called the cardiology Attending at home who then came to the hospital.

They came up with three possible, life threatening diagnoses: a heart attack, a tear in the aorta, or a blood clot in the lungs.

Each specialist was advocating for a different plan though. When I read this each one felt very much what I would have expected each one to suggest. The OB wanted to delivery the baby right away because of the increasing fetal distress. The anesthesiologist wanted to continue to wait for a more clear diagnoses. The ED attending suggesting intubating the patient which would also help support her during further evaluation. The cardiology attending suggested moving the patient to an area where they could put in a catheter that would reach the heart and give a more definite diagnoses.

A more definitive diagnoses could also be made with CT imaging, but there was a concern about moving the patient so much and it was unclear if they’d be able to move them from the operating room to the CT scanner to the ICU along with concern about exposing the fetus to the radiation.

We don’t get to hear much about how they reached the conclusion, only that they did so in a short amount of time (less than an hour), but they decided to prioritize the mother over the child and also to use an ultrasound to check for the tear in the aorta since that is the most dangerous and fast one in the list.

This allowed them to avoid moving the patient so much. The ED Attending convinced the group to intubate and make one move straight to the ICU where they could do everything.

The ultrasound eventually revealed that there were in fact, two problems, a big tear in the aorta and a large heart attack at the same time.

This case shows us one example of how resilience can emerge, even in the face of hierarchies and ways of working that don’t foster it. We can see examples in how the doctors adapted to the situation as the patients condition changed and their understanding of the situation changed as well.

The doctors, each in their own speciality, working together can be seen an as example of a distributed cognitive systems. They were directable, changing their action plan as new information or suggestions came in. They demonstrated the shifting perspectives when each spoke for their own specialty. This helped think of more options and not get stuck with tunnel vision.

Though this case doesn’t get into the how this happened, as it’s likely impossible to know for sure. Though it is clear that this sort of collaborative work is typically not fostered in healthcare. The authors do share a few factors that they think may have contributed. Perhaps it was the individuals themselves, or the difficulty of the case, or even perhaps that it was a rare case.

Either way I think its something we can learn from and use a lens to look at our own work. Where are we working more sequentially instead of collaboratively? Where does hierarchy impose barriers towards collaboration? Would it take an emergency for us to move out of those ways of working?

Takeaways

• Resilience can emerge even in situations where the predominant hierarchy doesn’t foster it, or even the domain as a whole
  • Though sometimes this may require working outside of that hierarchy.
• Sequential, instead of collaborative, work can be further reinforced by being unable to see other specializations or areas
• Not allowing a single individual or view point to dominate diagnostic attempts allowed the team to not get trapped in just one approach, though each member spoke for their own speciality.
• The team was willing to adjust their strategies and even their goals as the situation changed.
• We can use cases like this to think of our own work and compare where perhaps we’re creating or enforcing barriers to collaborative work