“When you hear the call you gotta get it under way.”  – “Word Up!” (Cameo)


I am winding down this series on High Reliability Organizing and what it means to the emergency department by covering one of my favorite topics Commitment to Resilience.



  • Intrinsic ability of a system to maintain or regain a dynamically stable state.
  • Allows continued operations after a major mishap or in the presence of continuous stress.
  • Involves recognition that no system is perfect.
  • Combination of keeping errors small and of improvising workarounds to keep system functioning.


Normally in the section I would be writing what we can learn from the successes or failures of some other HRO. However when it comes to a Commitment to resilience –  WE OWN THIS.

Period. Hands down this belongs to us. I cannot think of any organization that faces adversity as frequently as we do (daily overcapacity, complex critical patients, a broken health care system) or as well.

It is no accident the motto: Anyone, Anything, Anytime resonates with us. It is part of our ethos and ego.


Just 30 minutes into July 20, 2012 a gunman entered a crowded movie theater in Aurora Colorado and began to fire multiple weapons into the crowd. Approximately 70 people were injured (including 12 killed) in the attack. Within 15 minutes patients began to arrive at the local hospitals at first by police car and then ambulance. At University of Colorado Hospital they had been at full capacity and on ER divert when these patients poured in from the ambulance bay. In the end all 22 patients sent to them survived as the full resources of the hospital were brought to bear. By 7am the next morning with all these trauma patients dispositioned their department returned to caring for all who sought emergent treatment. (The Night the ER Staff Can Never Forget)

This is an extreme example of the daily challenges faced in any emergency department. How often have you heard somebody describe the condition of their ER as “It’s like a Monday” and automatically know what that means?  Why do ERs do well with this?

Well mostly it is through practice. We have mini disasters or crises that occur all the time. The trauma patient, the cardiac arrest, the three phone calls simultaneously. We are forced daily to prioritize, multi-task and keep a wide field of vision. We are resilient simply because we expand what we do to meet the needs that present.

ED Sign


After such a glowing assessment of how well we can do what could I possibly write in this section? The truth is alot. That can-do attitude that makes us resilient also makes us complacent.

Or in other words “our system works exactly as it is  designed”.  If every Monday is busy and admits pile up why do we not plan for it?  We ED folk are sometimes more reactive than proactive. So while we are resilient are we fully committed to resilience?

  • Improving everyday operations is key. Smooth, well planned operations everyday pay off when disaster strikes.
  • Don’t change the system when crisis hits. Try as best as possible to stick to what has worked daily.
  • Know when to ignore #2. At some point all systems use up their “stretch” and have to go to Plan B. These moments are opportunities for great leadership as morale can sink quickly as confusion sets in.
  • Finally do whatever the charge nurse tells you they always no more about what is going on than anyone else.
Sharp End

Thanks for sticking with this series. In the next few weeks I will be starting “EDQA: Lessons from the Sharp End”  This will be an opportunity to highlight what we can learn from a structured QA process. The lessons will be both for improving the system and individual practice.