Hi. Thank you for watching this video. In this lesson, we're going to cover Applying the Results of the Pre- Mortem Exercise. After watching this lesson, students should be able to apply the results of the pre-mortem exercise, prioritize, identify barriers and challenges and create an action plan. To recap, the pre-mortem exercise is an exercise that teams can use to identify and surface barriers and challenges to project success during the project planning and sustainment phases. It's a four step process that first asks teams to imagine that it's one year out that the project has failed miserably. And what does the worst case scenario look like? During Step 2, participants are asked to imagine, what could have caused the project to fail? They were asked to identify all of the barriers and challenges that they're aware of to project success. In Step 3, The team works together to identify specific actions that they can take to avoid or manage issues that rise to the surface as being important to address at the project planning phase. Finally, overtime teams should review the results of the pre-mortem exercise to resensitize themselves to potential problems throughout the project, and to address issues that may not have deemed important enough to develop an intervention for during that first initial pre-mortem exercise. But that now, because those larger issues are out of the way can be addressed. The first step is to debrief responses. So in Step 2, the team has work to identify the issues that they think raise challenges and risks a project failure. After 10 minutes are up, the facilitator goes around the room asking everyone to share one reason from their list that has not already been mentioned, and this is repeated until all the reasons are identified. The reasons are then noted on a board or easel in the room for all to see. Sometimes, teams use posted notes where instead of writing on a piece of paper, a list each participant writes one identified reason for failure or threat on a posted note. In which case during this step, the facilitator can collect the posted notes one by one and put them together on a board for all to see. Once all the reasons are mentioned, the facilitator briefly reads through the reasons listed on the board. And at this point, teams often find it very helpful to afinitize or group together things that have common issues or stem from the same problem in a clinical area. After those are identified, team next prioritizes the top three or four concerns that are going to be addressed as a result of this initial pre-mortem exercise. The voting is usually done non-verbally. At the beginning of the pre-mortem, you've either given the team members each four stickers that they can use to dot vote, or a sharpie marker, say, that they can use to dot vote. And we'll talk about that voting in a minute. So, each team members told that they have two minutes and four votes. They are then asked to working independently, select their top four concerns from the items that were identified and then are listed either on posted or on the white board. To do this, you either use the four stickers to place either four concerns or they can put them all on one concern if they want to, or they can make four marks with the sharpie for their four issues. Again, they can use as many as they want, but they only get four votes. So if they feel that something is a particular problem, they may give that item two votes, and then one in one for two other issues, I think you get the picture. Once they've completed this, then the facilitator and the team identified the concerns that have the most votes. So those have risen to the surface as being based on the team's belief posing the biggest problem to success for the implementation of your intervention. So, it's easy then because the next step you're going to want to address just those concerns. So you're going to list those three or four top items on a separate piece of paper or board, or move the posted note to a separate piece of paper or a board. How can teams prioritize? Using a grid like this is one way the teams can prioritize concerns that rise to the surface or help them rise to the surface by considering the impact of the potential concern or barrier. So, is it a major reason the defect occurs, or is it a minor reason that the defect barrier occurs? And whether it occurs, rarely or has a likelihood of occurring again. So in this matrix you can see here in the upper right hand corner, major reasons why the defect occurred or major reasons why the issue poses a barrier and frequent occurrence are good targets for interventions. This may be where you want to start to focus your concerns. After the team has identified the top three or four concerns, its ask to brainstorm interventions that could be done during project implementation to mitigate that concern. A form like this one can be used for this process. You can see here, this is the pre-mortem results form, it has three columns. In the leftmost column, those three or four top concerns are written out. The next column is labeled interventions. In this column, for each of those top concerns, you're going to write what it is that you're going to do to address that concern, and this is going to be operationalized at a fairly high level. No, it's not enough just to say we're going to do X and sell, but instead what you really need to do is, say, what specific actions will be taken to achieve the goal of addressing the top concern. And then, for each of those steps, you're going to identify a person or persons who are going to take responsibility for making sure that that work gets done. For really easy things you, may just need one person to take responsibility. But for more complex problems, it may take more than one person, so you may need one, two, three people to take responsibility for a step or a goal of addressing a top concern. It's not important at this point how many people you identify, what's important is that you identify people who will take responsibility for making sure that these interventions are undertaken. Not all solutions are created equal. As you can see here, this graphic shows the continuum of strength of interventions that teams often take to address concerns. Some are weaker actions, there're intermediate actions, and then there are very strong actions that really if they're put in place, work in strong positive ways to prevent people from being able to do the wrong thing. And that's really what this is all about is making it easy to do the right thing, and making it difficult to do the wrong thing. So, often what we find is that these interventions are composed of some weaker actions, some intermediate actions, some weaker actions, some stronger action. So as you think about the interventions that you are going to propose, you want to keep in mind what's the strength of that action, and do you need to choose something from another, maybe one of these columns to strengthen the chance that that intervention once it's implemented, will address or mitigate the risks that the barrier or challenge proposes, so you may need to put a new policy in place. But I think that we all know that putting a new policy in place doesn't always achieve the goal of everyone using that policy, because it's difficult to change behavior. So that's why these other actions such as, mistake proofing, simplifying processes using checklists and structured communications, may also need to be bundled into your intervention. So that, yes, you've got a new policy, but now you've got additional actions that you're going to take that will make it easier for team members, front-line staff to use that new policy, and harder for them to not use the new policy, and continue to work in the way that they're working now. It's also important to realize that you need to engage all members of the front-line staff, administration and management who have something to bear on the process that you're trying to put in place in your quality improvement project. So the team needs to think about, who has influence and impact when it comes to making sure that your intervention will succeed? Once you've identified those people, it's really important that you understand whether they're likely to support or resist your intervention. And how you're going to engage that person to get them on board. And for people who are going to resist your intervention that's a real issue. Sometimes teams choose to give that person a role in the intervention to help to bring them around to perhaps accepting it. But it's also important to understand that just because someone resists your intervention, doesn't mean they're wrong, and there may be something that you need to learn from that person. And by including them on your team, you're bringing that person in, and you're benefiting from the benefit of their concern, which may in fact just make your intervention stronger. So you need to think about engagement, and you need to think about how you're going to get the team engaged across the board as you're implementing. Antoine de Saint Exupery said, "A goal without a plan is just a dream." It's important to create an action plan when you think about moving forward. Because an action plan is going to help you ensure that what you've decided you're going to do actually gets done and how it will happen. This is a pre-mortem exercise follow-up log and it's an example of what can be used as an action planning document. You can see here it's got a number of columns and rows. Across the columns here we have actions, who's going to take responsibility? And remember, that could be one or more people. The priority for that action, the status of the action. You'll see why you need a status column in a minute. The start date, and the end date, and then any notes. And then as you can see here down the left-hand side, the goals are the interventions that you're going to implement are listed. The reason that it's important to understand what the status is, is that this is a document. Because it's an action plan that the team is going to revisit at its usual team meetings, so that this will allow them to track the progress that the individual or individuals are making toward putting those goals in place. As you can see here, there's a start date and an end date. It's really important that you try to identify what the timeline for that particular intervention for that goal is, because it helps you to ensure either it's being done and that you should be revisiting it. And sometimes things are dependent, you can't move forward to the next step until step A is completed. So you need to have those start dates and end dates, so that you're aware of any progress or progression that needs to be made. And they shouldn't be arbitrary dates. But it's also important to consider that sometimes things occur that we can't predict, and so your end dates may need to move. But the beauty of that is that as you're reviewing these at the weekly or monthly team meetings, you'll realize if end dates need to be moved, you'll adjust accordingly. And if there's a problem with the end dates being missed, it may be that you need to rethink that intervention or that you need to get more people to volunteer to help put that intervention in place. So action planning is a really important part of this process because it is the way that the team knows, what it's doing, how it's being done, who's doing it, and what the progress is toward meeting the goal. Finally, it's important after the pre-mortem exercise that the team understands that this is not a one and done thing. The team will have responsibility for working on the interventions, and that they should review the pre-mortem results list at meetings. The reason to do this is because they need to make sure again that these are getting done. Also, if you periodically review the entire concern list, you'll identify new concerns that may be on the horizon or that are occurring. You can also go back and address concerns that were identified during that initial pre-mortem exercise but they didn't rise to the top of the list as needing immediate attention. But if you're fortunate to be able to have addressed your major concerns, you can now work your way down the list to address those concerns that now are worthy or deem your consideration, and get going with solving those potential problems.
