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Proceedings of the fourth Resilience Engineering Symposium

Erik Hollnagel
Éric Rigaud
Denis Besnard

Engineering Resilience Into Intensive Care Units

Jean Pariès, Nicolas Lot, Fanny Rome et Didier Tassaux

Texte intégral


1Intensive Care Units (ICU) are high risk, dynamic systems, characterized by the omnipresence of the unexpected, the diversity of situations and actors, as well as the presence of complex interactions at all levels. Recently, as a result of concomitant increased economic pressure and increased public demand for intensive care accessibility, the constraints on ICUs have been growing in an exponential manner. Even wealthy ICUs are regularly facing so called “overload” situations (patients number exceeding capacities, unexpected events, extreme medical cases), which reflect a mismatch between the perceived task demand and the quantity and quality of competencies needed to achieve this task with the current work organization. The challenge is then to maintain an acceptable level of performance in terms of productivity, care quality and patient safety, and also staff working conditions, despite the associated deteriorations of the functioning conditions. Often, when the current, normal, capacities are exceeded, new practices emerge, that will maintain performance at an acceptable level. These adaptations, which are not formalized, are experienced differently by different actors, and they can take either negative connotations (risk taking, failure to follow protocols, guilt feeling), or positive connotations (increase in service performance, personal achievements ...). One can assume that better recognizing and understanding these daily adaptation mechanisms could allow to improve ICUs’ capacity to manage diverse or exceptional situations, and beyond this, to engineer resilience into the ICUs’ features, in other words to incorporate it into the genes of the organization.

2Building on the above assumption, the Geneva University Hospital (HUG) ICU has decided in 2010 to undertake a research to better understand its own resilient capacities, and possibly derive strategies to further improve them.

3The first phase of the study focuses on describing the mechanisms of collective resilience as they can be observed in the actual activity of the ICU operators. The non-nominal situations encountered are characterized along several dimensions including their unpredictability, their rarity and their criticality. A grid of resilient features is adapted from the Resilience Assessment Grid (RAG) to be applicable to ICUs. Direct observations of daily activities and emergency situations allow understanding the constraints and practices of different professional groups, as well as their coping strategies. The results will determine whether and how coping strategies differ depending on the situations encountered, and describe the contribution of various factors such as anticipation, meta-knowledge, access to information, dissemination, protocols, mutual assistance, transmission and sharing of skills, intra-groups diversity, or shared values and objectives.

4The second step is intended to derive resilience engineering lessons from the outcomes of phase one, in order to experiment them for the ICU organization. We will seek to understand to what extent the adaptability of individuals and the observed collective adaptation mechanisms can interact positively and contribute to generate organizational resilient conditions. This step will also build on the work of the working group "Priority Goals Focused Simplified Procedures" currently established within the ICU, and intended to develop simplified protocols based on the “positive deviance” in current practices and dynamic routines. Unlike static routines that represent the ability to replicate tasks, dynamic routines are oriented towards learning and developing new responses and processes.

5A third phase is also planned, during which the results from phase one and two will be confronted to the critical review of an expert panel composed of the managers of all the intensive care units within French speaking Switzerland.

6The presentation will describe the conceptual issues addressed, the research protocol and the expected outcomes.


Dédale S.A.S. 15 place de la Nation 75011 Paris ;

Dédale S.A.S. 15 place de la Nation 75011 Paris;

Médecin adjoint, Service des Soins Intensifs, Hôpitaux Universitaire de Genève
Rue Perret-Gentil 4
Genève 1211 Genève 14, Suisse

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