Resilient health care performance in the real world: fixing problems that never happened

BACKGROUND: Staff in health systems everywhere have exhibited flexibility and a capacity for improvisations during, and in response to, the COVID-19 pandemic. Looking to other examples of such resilient behaviours outside of those induced by the pandemic is instructive for those involved with researching or understanding change, or making health systems improvements. METHODS: Here, we synthesise and then assess the value of eight case studies of in situ resilient performance from Canada, Sweden, Japan, Belgium, the United Kingdom, Norway, the United States and Brazil. The cases are divided into four categories: responsiveness to a crisis; adaptiveness over time; local adoption in accommodating to a top down, national policy change; and the consequential outcomes of an intervention. RESULTS: The cases illuminate the resourcefulness of translational and social researchers in examining such behaviours and practices. More than that, they also foreground the ingenuity and adaptive capacity of staff on-the-ground who continually anticipate, respond and adapt to make systems work and provide continuous care in the face of many challenges, including resource deficiencies, policy misalignments, and new technologies, policies and procedures that need to be integrated into local workflows. Front line clinicians make care systems work, pre-empting issues and sorting out problems before they occur or as they arise. CONCLUSIONS: A key lesson amongst a range of findings is that, rather than focusing on shiny new tools of change (checklists, frameworks, policy mandates), it is much more insightful and satisfying to deeply apprehend care at the sharp end, where clinicians deliver care to patients, understanding how everyday work is executed. This, rather than the Health Ministry, the Boardroom, or the Management Consultant's office, is where and how change is being enabled, and where street level actors solve problems, thwart issues in advance, and constantly avoid pitfalls.