Building A Safety Management System For Infectious Disease Outbreak Control In the Netherlands: An Exploratory Study

Building A Safety Management System For Infectious Disease Outbreak Control In the Netherlands: An Exploratory Study

Zhu, W.

Ale, B. (mentor)
Koornneef, F. (mentor)
De Bruijne, M. (mentor)
Van Steenbergen, J. (mentor)

Technology, Policy and Management

Safety Science Group

Management of Technology

2012-07-19

This thesis explores to build a Safety Management System for infectious disease outbreak control in the Netherlands. Q-fever and Salmonella were two major disease outbreaks in the past decade. The outbreak management were criticised for ineffective implementation of control measures, and the magnitude of the outbreaks increased by years. Although they were not as contagious and lethal as pandemics such as SARS, but the well-being of the people were threatened. Moreover, the two outbreaks did not end well: relevant actors had fallen victim to last-minute remedies which cost a large proportion of their properties. RIVM (National Institute of Public Health and Environment) has initiated a project to investigate the past outbreaks, aiming at a clearer understanding of the complexity of the situation back in time during the outbreaks, and calling for strategies for improving the outbreak management system in the country. The research project started with studying four evaluation reports on Q-fever and Salmonella. Phase I of the research focused on reconstructing chains of events, which led to root causes analysis of unwanted events. Fact reconstruction tool Event and Conditional Factors Analysis+ (ECFA+) was used to analyse the two cases. Significant events were picked from the resulted ECF chart, and underwent Cause Change Control Analysis (3CA), out of which work controls/protective barriers and root causes of the significant events were obtained. Results of ECFA+ and 3CA were revised within the project team with the attendance of an expert from RIVM. Phase II of the research focused on system building and discussion. A Risk Management System (RMS) for outbreak control and a companion Business Process Model (BPM) were constructed to address the controls or protective barriers identified in the 3CA analysis. Organisational Learning (OL), as an embedded process in a risk management system, was mapped to the RMS, and then barriers to organisational learning were discussed. After a focus group discussion, recommendations were given in terms of a guideline of gap analysis for the safety management system, as well as how to tackle the barriers to organisational learning in the system for outbreak control. This exploratory study attempted to combine incidents investigation tools (ECFA+3CA), using abductive reasoning as a base to formulate explanations for the occurrence of unwanted events and to build a safety management system preventing such occurrence. The resulted RMS steps and business process model added systemic perspectives to the infectious disease outbreak control management in the Netherlands.

infectious disease
outbreak management
incidents investigation tools
safety management system
risk management system
organisational learning

http://resolver.tudelft.nl/uuid:ae0ceacc-e2a8-451f-ba23-caf501e9ad45

Student theses

master thesis

(c) 2012 Zhu Wei, W.