Keeping patient safety and quality improvement projects on track, on time, and on budget is critical to ensuring their success. In this course, students will be introduced and given the opportunity to apply a series of tools to guide and manage patient safety and quality initiatives. These include tools for defining what success looks like, developing a change management plan, and conducting a pre-mortem to identify risks for project failure. This course will also provide tools for engaging stakeholders to ensure key players are invested in your project’s success.
Pre-Mortem Demo Exercise
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Do curso por Johns Hopkins University
Designing for Sustainment: Keeping Improvement Work on Track (Patient Safety IV)
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Conducting a Premortem
In this module, learners will develop an understanding of what the Pre-Mortem exercise is and how it can be used to: improve project planning, surface threats to project success and sustainment, develop interventions to mitigate risk of project failure, create an action plan to maximize the application of Pre-Mortem results, and maintain awareness of threats to project success across the project lifespan. Learners will also develop familiarity with facilitation best-practices. The Pre-Mortem Exercise can be a powerful tool to identify and mitigate risks for project failure.
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Lisa H. Lubomski, PhDAssistant Professor
Department of Anesthesiology and Critical Care Medicine
[MUSIC]
Hi team, thanks for joining me today.
I'm Cheryl Conners, and I'm going to be your facilitator for
the pre-mortem session.
And if you don't mind,
I'd love to go around the room and just have you introduce yourselves.
I understand that you're a multidisciplinary team that
serves patients on this unit, but I always like to put a face with the name, so.
>> Hi, my name is Natasha Speed.
I'm the quality improvement specialist, and
I support several projects on this unit.
>> Hi, I'm Dave Thompson.
I'm the charge nurse for the day shift here on this unit.
>> Hi, I'm Lisa Leblonsky, and I am the unit manager.
And I oversee a lot of the activities that go on in this unit,
make sure we have what we need to do our job.
>> I'm Erin Kerley, I'm a physician here in the unit.
>> Well, great, it's wonderful to have you guys here today.
So as you know, we got our safety culture assessment results back.
And it looks like we have some room for improvement in the teamwork domain.
And as a result,
our leadership thinks that we should be focused on the teamwork domain.
And I understand that you all went through the two-day team steps master training,
is that right?
>> Yes.
>> Our goal is to, before we implement the team steps master training,
is to do a pre-mortem, as we do with many projects and programs,
to anticipate any of the barriers that we might encounter as we
are implementing team steps in our unit.
So pre-mortem, typically what we're going
to do is we're going to imagine that we're one year into the future.
And our team steps implementation in our unit has completely failed.
Things have gone completely wrong on a number of fronts.
What could have been a cause for this?
Please spend the next ten minutes writing down the reasons that you believe
this failure occurred.
For that, I've provided you with some Post-it notes and
some Sharpies or pens that you can use.
And what I would encourage you to do, for good brainstorming,
is write one idea on each Post-it note.
So don't save the Post-it notes.
We'd like to have more Post-it notes generated.
And then what we'll do is we'll post them on this white flip chart and
see if any themes surface.
And then we'll do some voting to decide where our highest priorities are and
try to come up with two or
three factors that might threaten our team steps implementation.
Sound good? >> Yes
>> Great.
So now that you guys have taken the time to represent your diverse independent
thoughts on Post-it notes, let's have each one of you tell us the factors
that you think are going to threaten our team staff implementation.
And then you can hand me each one and I'll post it up here before we go into voting.
>> Okay, so I'll kick off.
So one is that we're rolling out a new EMR system.
>> I imagine that'll cause a lot of issues.
>> So this is a competing priority.
I actually have that one, too.
>> Okay, I'm going to make that a category, I think.
>> Also, poor communication, I think is one of the reasons now that we're in year
end of this project that's a big fail.
>> Okay.
>> Lack of trust for proposed changes.
Not sure if everyone has got into the mood for change just yet,
or implementing some of the team stuff.
Activities, I'm not that we were able to establish a shared mental model,
so maybe not a good one.
So that may go along with- >> Communication maybe, trust?
>> It probably could maybe go with both, in a sense.
>> Why don't we put it in the middle here and see?
>> Maybe if there was proper communication,
we could have established a shared mental model, possibly.
No project management structure.
>> Okay.
>> I think I kind of created a few things because that probably pairs with this one
which is lack of accountability structure.
>> Okay, so I'm going to stick that right here for now.
>> Limited resources.
>> Perhaps that can fit here as well.
>> And last but not least,
I hear a lot of people complain no protected time on staff.
>> Time, time is an issue.
So maybe we'll stick that somewhere around here.
All right, David, do you want to share yours with us?
>> So I tried to be a little bit positive in not only,
this is why we're going to fail, but what we might be able to do about it.
Make participation and team steps part of our yearly evaluation.
because I think if people are not, it's not in their evaluation,
they're just going to take the class and then not pay attention.
>> Okay, I'm going to put this in a totally different category over here,
because it sounds like it's funneling into the solutions.
>> I want to, we know our culture is bad, and this is supposed to fix it.
But I think for
those individuals that we know are problematic, and we all know who they are,
highlight their team steps behaviors at the class we want them to be adopted.
I think if we don't do that, they're not going to do what we want to do.
They're not going to be a team player because they're not team players already.
>> Okay. >> And they don't care about things.
>> So we have to embrace the dissenters.
>> Embrace the dissenters.
>> Engage these guys.
>> That's always the way that we do this.
>> Okay.
>> And as Tasha had said, we have no protected time.
We were getting four hours every month and now we don't.
>> And I think one of the things that we can do is assess knowledge of the staff.
And I've done this before.
There are quizzes in the back that if we just show
that not only did we have the training, but we see that it's effective.
And if we see we're not effective,
then we know that we need to hit this from a different perspective.
>> Okay. >> So I think this
is one of the big reasons we would fail if we don't let
them know that we are going to check to make sure.
>> Okay, even though we're not finished doing our deep dive into what we think
the threats are going to be, we already have some great solutions to think about.
So once we are able to better identify the problem,
we'll be able to pick a solution and generate some more brainstorming around
what we're going to do to mitigate the threat.
So I am going to keep these over here for now, and then Lisa,
could you share with us what you have?
>> I have, as we've seen before when we've tried to do some things,
that people may just not use the tools.
And then I know David knows this for sure,
in the past year we've really used a lot of agency in float pool.
>> And if those people don't come in trained with team steps,
they don't understand it.
>> Sure, I'm going to put this with resources for sure.
>> And then I wonder if the timeline that the leadership has given us is really
very realistic?
>> Okay, competing priorities?
>> Mm-hm. >> Fits nicely, okay.
>> And then I guess these are two that I didn't see, but
I think they certainly reflect some of the other things up there.
I wonder if the hospital, if hospital health system leaders
don't really stand behind this team steps initiative.
>> So we need buy in from the top and we need to model the behaviors, too.
>> Yes, that's what I'm saying.
>> Okay.
This sounds like a new category.
>> And then the last one I have is that, I just think we need to make
sure that we give people a compelling reason to use team steps.
If people don't see it as being important, and
I think that was something that David said,
then they'll go through the training, but they'll just be going through the motions.
>> Do you guys think the compelling reason then fits with maybe the lack of trust and
establishing a shared mental model and communication?
>> Yeah.
>> Okay, I'm wondering, too,
if even that leadership buy-in doesn't fit somewhere in up there, too.
But I'll leave it there for now.
If you guys want to move it, we can move it before we go into the dot-voting.
Okay, Dr. Curley, what do you have?
>> Well, one of the things that I was thinking about it, and it may
be in several of these categories, is how would we know if it's working?
So do we have data to back it up to support extra buying and
to encourage people to trust this initiative?
>> That's why I wanted to do the assessment knowledge in six to nine
months, because I think if you can't show them that we're making a difference,
either we've done it wrong or they're going to lose interest.
>> You have to show those milestones.
>> Yeah.
>> The next one that I have was, again, on the competing priorities.
People are pulled in different directions constantly.
So meetings aren't attended, or they're attended by the same few people.
So they're not necessarily have like equal buying from all of the front line.
>> Meeting priority sounds like a concern from all angles at the table.
>> Right, and then finally there's been high turnover on the units.
So our efforts lack continuity.
And don't necessarily feel cohesive with new people coming in,
they don't necessarily get the same training.
>> Okay, I'm going to put this with the limited resources.
Any others?
>> No, everything else was already.
>> So just to recap,
what I think you all said was there are some categories surfacing here.
So we have this competing priority category, and
then we have a shared mental model category that includes trust and
communication, compelling reason using tools.
And then we have the resource category.
And I think it hits on the people resource, the accountability,
the training.
And then we have also time which could maybe,
do you think it could fall under resources as well or should it stay separate?
>> I think in some ways it should stay separate,
because we're using the float and the travelers.
And until we get back to our normal staff,
we are not going to get our protected time back.
So there's money to provide for that time,
but we spend more on FTEs when we have to use travelers and float people.
>> Okay, great.
And then how about the metrics and knowing what the impact is?
I'm wondering if that, too, doesn't fit into the shared mental model, so
getting the buy-in, and then showing everyone the impact.
>> I guess it kind of depends on what the root of it is,
because it could be a resource issue, right?
Meaning, no one's tracking it because we don't have the resources.
>> True. >> But
also, it could potentially even fit in the accountability and project management that
we had planned for someone to track it if we didn't have the resources.
So it's one of those that I could see it fit into several categories.
I know that's probably not helpful, but it's getting at the root of it,
what caused a lot.
>> Yeah, well, I think that is helpful.
Does everybody feel good about what we came up with so far?
Is anything missing?
Yeah, I don't think so.
>> No? >> I think this is a really good place to
start.
>> Okay, so it sounds like we're ready to move into dot-voting.
Each of you got four dots.
And the rules of dot-voting are,
you can put all four dots on either one theme or one Post-it note,
if you think that's the biggest threat to the work we're about to do.
Or you can put one dot per Post-it note, however you
perceive this to impact our team steps implementation.
When you're doing the dot-voting, what you might want to think about is,
is this a major reason or a minor reason that might contribute to failure?
And is this something that would occur often or rarely?
Okay, so obviously if it occurs often and it's a major reason, you might want to put
your dot next to that Post-it note or to that theme category.
So go ahead and put your dots on the board.
You can get in here, Dr. Curley.
>> Okay, why thank you.
>> [LAUGH] Yeah, I think it's a good idea to start with four and
see if any opportunities surface.
And if not, then perhaps we can do a second round of voting.
It does look like there's certain Post-it
notes that actually have quite a few dots on there.
And so I'll read them out loud and then maybe you can tell us what you were
thinking while you were dot-voting and how we should now move forward.
So it definitely looks like, how are we going to know this is working?
How do we know our program is working?
Do we have data, seems important?
And then we need to make sure that we give people a compelling
reason to use team step, seems also important.
And that people not using the tools would be certainly a threat.
And then we have on one dot each on didn't establish a shared mental model,
which kind of fits with these two Post-its here.
And then lack of trust for purposed changes as well as one for
lack of accountability and then one for high turnover in the unit.
So let's have some discussion about what you guys think.
>> Well, I think to Dr. Curley's point, it really is important for
us to know whether we're successful.
And I know they based this decision on the results of our last safety
attitudes questionnaire assessment.
But we only do that every two years, and
we can't really wait two years to know whether we're having success.
>> So does everybody feel that this here is a major reason that
would occur often as a threat to failure?
>> Yeah.
>> Okay, so I'm going to put that Post-it in this top
category over here as maybe a target for us to focus on.
And then maybe we can pick two others and plot them in our grid.
And then decide what action are those we're going to choose and how many.
So what next?
>> I think it's the tool use, because we've had teamwork training before.
And we made it interdisciplinary, we tried to do everything right.
And remember how we said that the physicians got up and
left in the middle of the training?
And we said, do you know how to do this?
And they said, yes, I know how to do a briefing.
And then we went to watch them, and they know what a briefing is, but
they could not do the briefing.
>> Yeah, and I'm wondering too, if using the tools is not just a training
of the tools but understanding the reason why we're doing it.
So does this go hand in hand?
>> Right.
>> Yes. >> Okay,
do we all think that this would be a major reason that would often threaten?
>> I think so.
When you look at the models for change management, they all say that,
you have to kind of make that burning platform to get people on board.
Okay, all right, so I'm going to put this up here too,
not any less important, but about equally important.
And then, so that we could make sure we're effective as a group and
not bite off more than we could chew.
Should we just stick with this for now and
decide on what actions we're going to choose to mitigate these threats?
>> Yeah, let's do that, and we can reconvene later.
>> Okay.
Okay, so now let's go back to David's ideas.
When we were doing our brainstorming session he was already thinking of
potential action items or solutions that could help mitigate the threats.
So the first one that we have here is assess
knowledge six to nine months after training.
And that sounds like it might fit with the potato.
>> Mm-hm, mm-hm.
>> The portion.
And then we have, make participation in team steps part of a yearly evaluation.
So it's not just this one time training,
but there would be ongoing training, if that.
>> That's usually how it's successful.
Everybody thinks you go to training and you got everything down.
But this comes from aviation, and the aviators,
they have to have training almost yearly, every 12 to 18 months.
So we think it's a one time only, but it's really not to be successful.
>> Okay. >> And
I think another thing in addition to those two is what do you think if we.
We're thinking about redoing the unit orientation for all of the staff levels.
And what do you think if we included at least some initial team steps
knowledge in that orientation for new staff and for the residents?
>> because that'll sort of help to address two things, I think.
This issue and then the issue of the turnover and using agency.
>> Sure.
>> Yeah. >> That'll be great.
>> And actually, this one here, regular train the trainer,
that also might address those factors.
>> Mm-hm. >> Yeah.
>> And should we actually, thinking of the training and the data collection.
Should we also do a baseline data collection?
So we assess where people are at the point of training, so
it's six to nine months later and then on a regular basis.
>> Okay. >> We could also have kind of
a pre-assessment, kind of a pretest, what's your knowledge going in.
>> Mm-hm. >> And I think that,
that might be really helpful.
Especially if we're going to look at it at six to nine months.
Maybe immediately in six to nine months, do they retain it?
Do they actually use it?
>> I think this is a great point.
And perhaps it could help us highlight
the team steps behavior to give us another solution that you can have up here.
Once we have a good understanding of their baseline knowledge,
deciding on what behavior we're focusing on to adopt or
integrate into practice, and then reassess.
>> And it might be nice even when we're assessing their knowledge to have a place
on the form where we ask about their current challenges or barriers.
>> So we can address that maybe in being able to
highlight those team step behaviors as well and the trainer trainers.
So we're taking feedback from them, not only on their assessment of knowledge, but
also the challenges of barriers they've encountered.
>> Great, great idea, so I just wrote that on the baseline data post-it.
Okay I think do you guys feel like anything is missing?
Do we want to explore other action items, or
do we actually feel like we have a good handle on this?
>> I think this could keep us busy for a while.
>> I agree, I agree.
Do we think it's realistic?
>> Yeah, we're pretty dedicated.
I think we could this.
>> Okay.
>> I think we could do this.
>> Great, so how about we have extended our time for today.
We plan to have our next meeting within the next month, and
then we get on a regular meeting schedule.
So that we could create our tools and a timeline and
actually mitigate our potential threats to our team steps implementation.
>> Sounds good.
>> [CROSSTALK] >> Thanks Cheryl.
>> Thanks you guys for your time today!
>> You're welcome.
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