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Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.

Failure to rescue events, or events involving preventable deaths from complications, are a significant contributor to inpatient mortality. While many interventions have been designed and implemented over several decades, this patient safety issue remains at the forefront of concern for most hospitals. In the first part of this study, the development and implementation of one type of highly studied and widely adopted rescue intervention, algorithm-based patient assessment tools, is examined. The analysis summarizes how a lack of systems-oriented approaches in the design and implementation of these tools has resulted in suboptimal understanding of patient risk of mortality and complications and the early recognition of patient deterioration. The gaps identified impact several critical aspects of excellent patient care, including information-sharing across care settings, support for the development of shared mental models within care teams, and access to timely and accurate patient information.

This chapter describes the use of several system-oriented design and implementation activities to establish design objectives, model clinical processes and workflows, and create an extensible information system model to maximize the benefits of patient state and risk assessment tools in the inpatient setting. A prototype based on the product of the design activities is discussed along with system-level considerations for implementation. This study also demonstrates the effectiveness and impact of applying systems design principles and practices to real-world clinical applications.

The purpose of this paper is to discuss strategies for benchmarking patient safety using Lombardy region administrative archives. Patient safety indicators and statistical methods are presented that allow risk adjustment. The analysis benchmarks regional health structures, focusing on two patient safety indicators: failure to rescue; and death in low mortality diagnostic related group.

Data were drawn from a research project promoted by the Italian Agency of Regional Health Services in 2002 to furnish statistical evidence regarding adverse events based on Agency for Healthcare Research and Quality indicators and methods. Hierarchical models for an equitable benchmark analyses are proposed.

Empirical analysis shows that hierarchical approaches, based on comparing health structures within homogenous specialties, disaggregates and moderates failure to rescue variabilities existing between hospitals, especially in oncology, intensive care and general medicine.

The paper proposes using hierarchical models for properly benchmarking health structures, resolving logistic regression drawbacks and limitations.

The paper strengthens the theory that accurate coding supported by software and administrative databases could provide a valuable and economical source for patient safety research.

The paper analyses and suggests strategies for consistent benchmark analyses based on patient safety outcomes, applicable to several situations and different health structure typologies.

The purpose of this paper is to introduce translational mobilization theory (TMT) and explore its application for healthcare quality improvement purposes.

TMT is a generic sociological theory that explains how projects of collective action are progressed in complex organizational contexts. This paper introduces TMT, outlines its ontological assumptions and core components, and explores its potential value for quality improvement using rescue trajectories as an illustrative case.

TMT has value for understanding coordination and collaboration in healthcare. Inviting a radical reconceptualization of healthcare organization, its potential applications include: mapping healthcare processes, understanding the role of artifacts in healthcare work, analyzing the relationship between content, context and implementation, program theory development and providing a comparative framework for supporting cross-sector learning.

Poor coordination and collaboration are well-recognized weaknesses in modern healthcare systems and represent important risks to quality and safety. While the organization and delivery of healthcare has been widely studied, and there is an extensive literature on team and inter-professional working, we lack readily accessible theoretical frameworks for analyzing collaborative work practices. TMT addresses this gap in understanding.

Bank regulation tends to develop as a reaction to bank insolvencies. Much of the detail of regulatory measures, comprising EU Directives, statute and guidance from the Bank of England is intended to enable banks to avoid collapse. The Bank of England's role and duties as prudential supervisor of banks is much more ambiguous than would be expected from this pattern, however. The Bank's effectiveness as supervisor has been subject to criticism since the Barings debacle, calling into question the purpose of bank regulation. After explaining the existing legislative and practical background to supervision of troubled banks, this paper considers the importance of protecting depositors as a guiding principle of regulation and explores possible developments.

Four psychoanalytic consultants, each utilizing one the most prevalent theoretical orientations used in the field of psychoanalytic consulting are asked to explain why a consultation succeeded. Using differing theories the four psychoanalysts reach the same conclusion. They conclude the consultation succeeded because of the consultants ability to manage and benefit from the intense transference reactions of the organization’s staff. These analysts suggest that the work of psychoanalytic consulting may be much more similar to the work of clinical psychoanalysis than previously assumed and that the key to understanding why a consultation succeeds or fails can be found in the analysis of the transferences in the relationship between the consultant and consultees.

The purpose of the study was to explore in literature what different leadership styles and behaviors of head nurses have a positive influence on the outcomes of patient safety or quality of care.

We reviewed the literature from January 2000 until September 2011. We searched Pubmed, Embase, Cinahl, Psychlit, and Econlit.

We found 10 studies addressing the relationship between head nurse leadership and safety and quality. A wide array of styles and practices were associated with different patient outcomes. Transformational leadership was the most used concept in the studies. A trend can be observed over these studies suggesting that a trustful relationship between the head nurse and subordinates is an important driving force for the achievement of positive patient outcomes. Furthermore, the effects of these trustful relationships seem to be amplified by supporting mechanisms, often objective conditions like clinical pathways and, especially, staffing level.

This study offers an up-to-date review of the limited number of studies on the relationship between nurse leadership and patient outcomes. Although mostly transformational leadership was found to be responsible for positive associations with outcomes, also contingent reward had positive influence on outcomes. We formulated some comments on the predominance of the transformational leadership concept and suggested the application of complexity theory and political leadership for the current context of care. We formulated some implications for practice and further research, mainly the need for more systematic empirical and cross cultural studies and the urgent need for the development of a validated set of nurse-sensitive patient outcome indicators.

Recent reports by the Institute of Medicine (IOM) signal a substantial yet unrealized deficit in patient safety innovation and improvement. With the aim of reducing this dilemma, we provide an introductory account of clinical error resulting from poorly designed systems by reviewing the relevant health care, management, psychology, and organizational accident sciences literature. First, we discuss the concept of health care error and describe two approaches to analyze error proliferation and causation. Next, by applying transdisciplinary evidence and knowledge to health care, we detail the attributes fundamental to constructing safer health care systems as embedded components within the complex adaptive environment. Then, the Health Care Error Proliferation Model explains the sequence of events typically leading to adverse outcomes, emphasizing the role that organizational and external cultures contribute to error identification, prevention, mitigation, and defense construction. Subsequently, we discuss the critical contribution health care leaders can make to address error as they strive to position their institution as a high reliability organization (HRO). Finally, we conclude that the future of patient safety depends on health care leaders adopting a system philosophy of error management, investigation, mitigation, and prevention. This change is accomplished when leaders apply the basic organizational accident and health care safety principles within their respective organizations.