Resilience Engineering in healthcare: A new perspective to understand healthcare organisations

Research output: ThesisPh.D. thesis

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The healthcare system faces significant and multifaceted challenges,including staff shortages, destabilising events like the COVID-19 pandemic,constant reorganisation, and increasing healthcare costs. An aging populationand the prevalence of chronic conditions is increasing pressure on thesecondary (specialised) healthcare system to coordinate ambulatory care inan efficient way for patients with multimorbidity. Traditional, linearapproaches have proven insufficient in addressing these complex challenges.

The aim of the PhD thesis was to investigate how work is organised and resource-utilisation in hospital outpatient clinic settings, and whether a Resilience Engineering approach can be applied to understand and improve the healthcare delivery and its potential for resilient performance. Resilience Engineering was chosen for this study because it is an approach that embraces the inherent complexity and dynamics that characterises the healthcare. The thesis addressed two main research questions: 1) How is the hospital outpatient work organised and how are resources utilised in the context of same-day visit and patient referrals?, and 2) How can the Resilience Engineering approach be applied to understand and improve the outpatient clinic’s potential for resilient performance?

The research questions were answered through a series of empirical studies conducted in the medical outpatient clinics at the University Hospital of Southern Denmark, Sønderborg (Sygehus Sønderjylland Sønderborg) and Macquarie University Health Clinics in Australia. The thesis is comprised of six inter-related studies, and used a mixed method approach involving both quantitative and qualitative methods.

Study I and Study II addressed research question one.

Study I used quantitative methods to understand the healthcare utilisation of patients with several trajectories in outpatient clinics at the medical outpatient clinics at University Hospital of Southern Denmark, Sønderborg from 01 October 2021 to 28 February 2022. The study found that 6.8% of patients attended two or more clinics at the medical clinics, with the most common combination being cardiology and pulmonary clinics. Among these patients, 9.4% of visits were already coordinated as same-day visits, while 21.5% had close proximity visits that could potentially be coordinated into same-day visits, highlighting the potential for more efficient resource utilisation by scheduling these visits together. Close proximity visits are defined as i.e. 1- 30 days between patients’ last visit and the subsequent visit in a different
clinic that could potentially be coordinated to same-day.

Study II used quantitative methods to examine the referral patterns to and between the medical outpatient clinics at the University Hospital of Southern Denmark, Sønderborg in September 2019. The study revealed that 6% of patients referred by General Practitioners (GPs) were also attending another outpatient clinic. An important finding was that one-third of the referrals from hospitals were from their own medical clinics (self-referral). These findings suggest that the referrals between the clinics may not be optimal.

In combination, study I and study II revealed that the system is not exhibiting resilient behaviours due to the fragmented patient visits across multiple clinics and suboptimal referral patterns between outpatient clinics.

Studies III, IV, V and VI were conducted to address research question two.

In connection with study II, study III aimed to understand and improve the referral process between the outpatient clinics using Resilience Engineering and LEAN methodology. Using a Resilience Engineering method, Functional Resonance Analysis Method (FRAM) was applied and identified that factors such as time constraints, lack of organisational structure to consult with colleagues and the need to adhere to documentation regulation to reduce medical risk liability led to the generation of unnecessary internal referrals.

The application of LEAN principles through Value Stream Mapping (VSM) highlighted that referrals were processed by physicians and secretaries in four steps or cycles, leading to prolonged processing times. These activities added to the workload of the healthcare staff without adding value to patient care.

The results of the FRAM and VSM were used in a Quality Improvement Project to improve the workflow between the outpatient clinics. The study also showed that FRAM and VSM are complementary methods and can be used synergistically to support process optimisation and organisational changes.

Study IV conducted a scoping review on the application of another Resilience Engineering method, the Resilience Assessment Grid (RAG), in healthcare understand and manage the resilient performance of complex adaptive systems such as healthcare. However, in the majority of the studies identified, it was unclear how the RAG questionnaire or tool was developed.

Based on the findings from study IV, study V focused on developing a RAG questionnaire to understand and support the potential resilient performance of the medical outpatient clinics. The study provided the medical department at the University Hospital of Southern Denmark, Sønderborg with knowledge about their baseline resilient potential and areas for improvement. These findings were discussed with staff and managers, leading to an emphasis on addressing these areas in the Quality Improvement Project to improve the internal collaboration between the clinics.

Study VI built on the work from study V. In study VI, we validated and explored the application of the Danish RAG questionnaire from study V in a different outpatient setting. This study was conducted at Macquarie University Health Clinics in Sydney Australia. The results demonstrated that the RAG questionnaire that was developed in study IV can be used in the same field in another setting in a different country to assess a healthcare organisation’s resilient strengths and weaknesses. At Macquarie University Health Clinics the RAG questionnaire was used by the managers to engage with staff, develop rapport and reflect on their work.

Overall, the thesis identified that the challenges faced by specialist outpatient clinics are similar to the complex challenges faced by other healthcare organisations. Through the application of RE approaches, the thesis provided a new perspective that can help healthcare organisations, such as the specialist clinics, understand how their system works and identify ways to improve it. A novel contribution of the thesis was the application of FRAM and the development of the RAG questionnaire for the outpatient clinic context, a tool that enables managers and leaders to assess their organisation’s potential for resilient performance and engage with staff. By adopting a non-linear approach, healthcare organisations are offered tools and strategies to manage resources and deliver high-quality care to address the dynamic and complex challenges they face. The findings and insights from this thesis provide a foundation for future research and practical applications in healthcare.
Translated title of the contributionResilience Engineering i sundhedsvæsnet
Original languageEnglish
Awarding Institution
  • University of Southern Denmark
  • Kristensen, Frans Hjelm Brandt, Principal supervisor
  • Clay-Williams, Robyn, Co-supervisor, External person
  • Thude, Bettina, Co-supervisor
External participants
Date of defence28. Nov 2023
Publication statusPublished - 30. Oct 2023

Note re. dissertation

Print copy of the full thesis is restricted to reference use in the library.


  • Resilience Engineering
  • Resilient Health Care
  • FRAM
  • RAG
  • Outpatient clinics
  • Resilience Assessment Grid
  • Functional Resonance Analysis Method


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