Table 2

Checklist for assessing institutional resilience (CAIR)

Indicators of resilienceYes?No
Yes = this is definitely the case in my institution (scores 1); ? = don't know, maybe, or could be partially true (scores 0.5); no = This is definitely not the case in my institution (scores 0).
Interpreting your score: 16–20 = so healthy as to be barely credible; 11–15 = moderate to high level of intrinsic resistance; 6–10 = considerable improvements needed to achieve institutional resilience; 1–5 = moderate to high institutional vulnerability; 0 = a complete rethink of organisational culture and processes is needed.
• Patient safety is recognised as being everyone's responsibility, not just that of the risk management team.
• Top management accepts occasional setbacks and nasty surprises as inevitable. It anticipates that staff will make errors and trains them to detect and recover them.
• Top managers, both clinical and non-clinical, are genuinely committed to the furtherance of patient safety and provide adequate resources to serve this end.
• Safety related issues are considered at high level meetings on a regular basis, not just after some bad event.
• Past events are thoroughly reviewed at high level meetings and the lessons learnt are implemented as global reforms rather than local repairs.
• After some mishap, the primary aim of top management is to identify the failed system defences and improve them, rather than seeking to pin blame on specific individuals.
• Top management adapts a proactive stance towards patient safety. It does some or all of the following: takes steps to identify recurrent error traps and removes them; strives to eliminate the work place and organisation factors likely to provoke errors; brainstorms new scenarios of failure; conducts regular “health checks” on the organisational processes known to contribute to mishaps.
• Top management recognises that error provoking institutional factors (e.g. under-manning, inadequate equipment, inexperience, patchy training, bad human-machine interfaces, etc) are easier to manage and correct than fleeting psychological states such as distraction, inattention, and forgetfulness.
• It is understood that effective management of patient safety, like any other management process, depends critically on the collection, analysis, and dissemination of relevant information.
• Management recognises the necessity of combining reactive outcome data (i.e. from the near miss and incident reporting system) with proactive process information. The latter entails far more than occasional audits. It involves regular sampling of a variety of institutional parameters (e.g. scheduling, rostering, protocols, defences, training).
• Meetings relating to patient safety are attended by staff from a wide variety of departments and levels within the institution.
• Assignment to a safety related function (quality or risk management) is seen as a fast track appointment, not a dead end. Such functions are accorded appropriate status and salary.
• It is appreciated that commercial goals, financial constraints, and patient safety issues can come into conflict and that mechanisms exist to identify and resolve such conflicts in an effective and transparent manner.
• Policies are in place that encourage everyone to raise patient safety issues.
• The institution recognises the critical dependence of a safety management system on the trust of the work force, particularly in regard to reporting systems. (A safe culture—that is, an informed culture—is the product of a reporting culture that, in turn, can only arise from a just culture.)
• There is a consistent policy for reporting and responding to incidents across all of the professional groups within the institution.
• Disciplinary procedures are predicated on an agreed distinction between acceptable and unacceptable behaviour. It is recognised by all staff that a small proportion of unsafe acts are indeed reckless and warrant sanctions, but that the large majority of such acts should not lead to punishment. (The key determinant of blameworthiness is not so much the act itself—error or violation—as the nature of the behaviour in which it was embedded. Did this behaviour involve deliberate unwarranted risk taking or a course of action likely to produce avoidable errors? If so, then the act would be culpable regardless of whether it was an error or violation.)
• Clinical supervisors train junior staff to practise the mental as well as the technical skills necessary to achieve safe performance. Mental skills include anticipating possible errors and rehearsing the appropriate recoveries.
• The institution has in place rapid, useful, and intelligible feedback channels to communicate the lessons learnt from both the reactive and proactive safety information systems. Throughout the institution the emphasis is upon generalising these lessons to the system at large rather than merely localising failures and weaknesses.
• The institution has the will and the resources to acknowledge its errors, to apologise for them, and to reassure patients (or their relatives) that the lessons learnt from such mishaps will prevent their recurrence.