‘Safety-II reflection in hospital practice: process description of the action research on a practical safety-ii tool: the safety-ii reflection cards’.

ABSTRACT: Introduction The Resilience Analysis Grid (RAG) is a Safety-II instrument to evaluate a systems potential for resilient performance based on the four resilience potentials Responding, Monitoring, Learning and Anticipating. Since its development, only a few studies worldwide tried to bring the RAG theory into healthcare practice. In the Netherlands, the Safety-II approach has become central to patient safety in hospitals. However, there are still few instruments available to support reflection on the resilient performance of hospital systems. Given that hospital work is predominantly team-based, hospital teams and their wards provide a valuable starting point for fostering reflection on resilience in healthcare settings. This study aims to identify key factors that facilitate the use of the Resilience Analysis Grid for evaluating resilient performance in hospitals while also introducing Safety-II principles into hospital wards. Method We applied action research methodologies to iteratively experiment with the RAG. In collaboration with healthcare professionals from the SAZ, an association of general hospitals, and Medirisk, a Dutch mutual insurance company, we explored how to apply RAG theory in practice. The study consisted of three phases. Phases 1 and 3 included online workshops with participation from all SAZ-associated hospitals. In Phase 2, we conducted RAG reflection workshops at the emergency wards of five SAZ hospitals, involving medical, nursing, and management staff. Throughout each phase, we observed the workshops and interviewed participants about their experiences with the RAG to identify key elements for its effective use. Results We identified several key elements that support the use of the RAG in hospital wards, ultimately leading to the development of the Safety-II reflection cards. These elements include the presence of a multidisciplinary group of healthcare professionals in the RAG reflection workshop, a facilitator with expertise in Safety-II principles, and a collaborative selection of a complex procedure for reflection. Additionally, fostering a shared language, cultivating an open culture, ensuring a willingness to dedicate time and space, and recognizing resilient performance as an ongoing work-in-progress are essential for effective implementation. Conclusions RAG theory, implemented through the Safety-II reflection cards, offers specific reflection principles that make the Safety-II perspective more practical for healthcare professionals when assessing their work procedures. These principles are particularly useful for complex processes in settings like emergency rooms and intensive care units, where they help strengthen patient safety.