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.
Facilitating a Pre-Mortem
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Del curso dictado por Johns Hopkins University
Designing for Sustainment: Keeping Improvement Work on Track (Patient Safety IV)
16 calificaciones
De la lección
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.
Conoce a los instructores
Lisa H. Lubomski, PhDAssistant Professor
Department of Anesthesiology and Critical Care Medicine
During this video, we're going to talk about
facilitating a pre-mortem exercise and facilitating in general.
This video will help teams who want to conduct a pre-mortem exercise to
understand what it takes to facilitate and how the pre-mortem can be successfully done.
After watching this video,
students should be able to identify
the roles and responsibilities of a meeting facilitator.
Recognize that there are challenges to successful discussions.
Use effective techniques to resolve those challenges and achieve a successful discussion.
Identify who should participate in the pre-mortem exercise
and assemble the supplies needed to complete the pre-mortem.
Facilitating is all about managing a meeting to achieve that the goals are met,
while ensuring inclusivity or that everyone is
participating in the exercise has the opportunity to contribute.
That doesn't mean they will,
It means we need to make sure that they're aware that they can if they wish to.
And hopefully, they will,
because this is all about getting the ideas and
information and wisdom of the people that are participating in the pre-mortem exercise.
The facilitator needs to ensure that the objectives are met effectively.
The facilitator also needs to achieve by in or get everyone on the team to reach
consensus about the outcomes of the meeting or in the case of the pre-mortem,
what concerns are that will be addressed,
and what interventions will be taken to address those concerns?
As you might imagine, this can be a difficult task and it
really requires someone with sensitivity.
And shall we say,
the people skills to ensure that everyone
feels like they have the opportunity to talk and contribute,
and that no one or two people dominate the conversation.
Not surprisingly, this list of responsibilities is kind of cut and dried here.
So, the facilitator needs to prepare in advance.
So, it's often the case that they'll meet with the team
that is planning the exercise to understand what the goals of the meeting are,
and what the outcomes are desired for the meeting or in this case the exercise.
They should plan and distribute an agenda.
This can either be done at the meeting itself or for
meetings where you really want to gather some thought you might think about,
distributing that agenda in advance to give participants a chance to think.
And that's not always done at the pre-mortem,
but it may be a good idea,
particularly if you think that you're in a particularly challenging environment.
The facilitator should be clear to state the objectives at the beginning of the meeting,
so that everyone who's participating understands why they're there,
and what they're going to do,
and what the outcome will be.
They should establish the ground rules for the discussion.
Then you're going to need to obviously by the name,
facilitate, guide the group in presenting and sharing information.
As I said previously,
to ensure that no one or two people dominate the conversation,
and to be as inclusive as they possibly can.
And they're also going to provide closure and reiterate action items,
so that everyone who participated in the exercise understands what was done?
What the decisions were that were made?
And who's going to take responsibility for which
action items that are resulting from the pre-mortem exercise?
Some of the ground rules that are commonly used are that,
team members should be here.
They need to participate in the discussion.
They need to provide their input and let people know what they think.
They need to stay focused.
Sometimes that means, no laptops and turn your phone off.
If you're looking at email or
your having side conversations during a meeting or during an exercise,
then you're not really 100 percent involved in the work that's being done.
If that's the case,
it somewhat can convey the idea that you don't think it's important.
They should remind the team members that all ideas are welcome, but not negativity.
It's important that everyone participating in the exercise, respects one another.
And finally, that only one person at a time should talk.
Often, the facilitator may find it difficult to keep the group on task and on time.
So, these are three common situations that may occur,
that the facilitator really needs to step in and address.
The first one, staying on task and on time isn't necessarily surprising.
When people are engaged and having an active discussion,
it's often the case that side topics or other issues and/or the conversation.
In such cases, the facilitator may need to
remind people of the focus of the meeting or use a technique called a parking lot,
where important or interesting ideas that
are raised but that are not pertinent to the discussion,
are written down and set it to the side for addressing later.
Dealing with unproductive behavior is unfortunately
also sometimes part of any facilitators role.
People may be paying more attention to their phone than they are to the meeting
or as it often occurs in discussions,
where people will have a point of view or
a preference about which they feel particularly strongly.
The facilitator may need to directly step in either by asking
them to clarify how their statements they're making apply to the topic,
or they may ask someone,
does anyone in the group have
a similar experience like Tom that they can contribute to the conversation.
They may need to talk to the person during a break or so to point out
that the behavior that they're displaying is not really helping
the meeting move forward or the discussion move forward,
respectfully suggest that they stop.
They may also find it that there may be a lull in the conversation
or the discussion may come to a natural end.
In such cases, if there's a lull,
and it doesn't seem to be a natural end.
The facilitator can stimulate conversation by using prompts or suggesting that the team,
"Should we move on to another topic?"
This allows everyone to ensure that they've really said all that they have to say,
that everything needs to be addressed is addressed and not remain painfully silent,
waiting to move on.
The pre-mortem is designed to help teams to
identify barriers and challenges to project implementation.
For this reason, it's really important that as
many members of the Quality Improvement Team as possible participate.
These are some of the people in roles
who you should consider including in the pre-mortem exercise.
The first are any quality improvement project champions,
often in a clinical area.
We have physician champions and nurse champions who are
helping to lead that project through the clinical area.
It's important that those people are involved in the pre-mortem.
The clinical area manager who has a role that involves making sure that
the frontline staff and others on the unit are
correctly and efficiently performing their jobs, should be involved.
That person may have particular insight into issues
around clinical area organization or management,
that may directly impact your project that others may not be aware of.
As I said, members of
the quality improvement team as many members of the team as possible.
And others who have particular knowledge or wisdom from
another clinical area or hospital administration who may have something important to
bring to bear during the exercise that can help to make sure that
all barriers and challenges that may appear are adequately considered and addressed.
It's important to consider the logistics of any meeting.
But the pre-mortem exercise in particular,
has some specific items that you'll need to make sure you have.
So, you should plan on at least one hour to complete the pre-mortem exercise.
In my experience, it generally can lead to a really robust and productive discussion.
And you want to make sure that you have time to really play that discussion out.
I understand that it can be difficult to plan a meeting that
involves all of the people that I just mentioned on the previous slide.
So perhaps you could schedule the pre-mortem exercise to
occur during a regular Quality Improvement Team meeting.
In that way, you don't have to find new time on people's calendars,
and you have some expectation that the team is already focused on,
being in the room at that time.
During the pre-mortem exercise,
the teams often need room to move around as they'll be
voting on different issues and concerns.
And so, you want to locate and reserve a meeting room that has
adequate space to be able to really do the pre-mortem.
You want to prepare the supplies that you'll need.
We'll go over that in a future slide.
And you want to make sure that you invite all members
of the Quality Improvement Team, Champions,
clinical area managers, and others,
so that they know where and when the pre-mortem exercise will take place.
These are some of the supplies that you'll need to do a pre-mortem.
It's important before you have
the pre-mortem exercise meeting to make sure
that you have these things in place and that they're in that room.
The pre-mortem input sheet,
which copies for everyone plus some extras,
we'll discuss the pre-mortom input sheet later.
But you could also use post-it notes and some teams also do.
Pens, pencils, and sharpie type markers are also one of the tools they're used.
And you might want to make sure that you have extras.
A flipchart, easel, and markers for writing on that
flipchart are easel or for whiteboards available, you can use that.
But you need some way to jot down input so that everyone can see what's been shared.
If you're using post-it notes,
you can stick them on the flipchart or the whiteboard.
But important to have a big space that you can
safely write on that everyone in the room can see.
Small circle stickers or sharpie markers are nice but they're not essential.
They are helpful though for teams if you do dot voting.
We'll talk about dot voting in a minute.
You want to have the pre-mortem results sheet in an action item follow up log.
PDF versions of these tools are available for you to download and use in your pre-mortem.
In facilitating the pre-mortem, step one,
you're going to explain the idea of the pre-mortem and provide instructions.
You're going to describe the pre-mortem.
You're going to encourage everyone who's participating in
the exercise to be open and honest because this is really
about identifying the things that they're aware of
that others may not be that pose a challenge to the success of the project.
You're going to hand out the pre-mortem input sheet or your post-it notes and a marker,
pen and pencil to each person.
This is the pre-mortem input sheet.
As you can see at the top,
it has the instructions for the pre-mortem exercise.
It includes three columns,
the first where each participant can identify the reasons for failure pre project.
Note their level of concern for the risk that
that item poses to the success or failure of the project.
Then, they can if they have time,
begin to think about action steps that they can suggest that could prevent failure,
with the mindset of what can I or
the team do differently that will prevent this from happening.
As you open the pre-mortem exercise, again,
you'll say, "Imagine that we are one year into the future.
And despite all the team's efforts this project has failed.
Things have gone completely wrong on a number of fronts.
What could have caused this?"
You'll ask the team to spend the next ten minutes writing down
all the reasons each person believes
this failure occurred and they will work independently.
And write down anything that comes to mind.
Again, either on the sheet or on a post-it note.
And if you use post-it notes,
you want one idea per post-it.
After about 10 minutes,
you're going to de-brief the responses.
You're going to go around the room asking everyone to
share one reason that has not already been mentioned.
And you're going to repeat this process until all the reasons are mentioned.
If you're using a white board or an easel,
you're going to record these issues on that board or easel using a marker.
If you're using post-it notes,
you can actually ask each person to either hand you their post-it note,
which you'll place on the board or they themselves
can stand up and put it on the board or easel.
But it's important that everyone in the room sees these reasons.
And then, once all the reasons are mentioned and identified,
you can briefly read through each of the identified reasons that's listed on the board.
And at this point, often,
it's helpful to start to group together
reasons that are similar or that seem to address the same problem.
This can be really helpful when you come
to the next step of trying to identify interventions.
The next step is to prioritize
the top three or four concerns that the group is going
to agree are significant enough risks that they should be
addressed and that an intervention should be developed to
prevent them or the risk that they pose.
The pre-mortem is usually done voting non verbally.
This really allows, again,
teams to overcome any reticence they may have about sharing their thoughts openly.
Each member is told that they have two minutes and four votes.
Voting can be done by either in advance providing
each participant in the pre-mortem with four circle stickers that
they can use to place next to that item on
the piece of paper or the white board or on the post-it note for that item.
Or they can use their sharpie to make a dot on those same paper or post-it.
But they need to remember that they can only vote four times.
Once they've completed this,
it's easy to identify the concerns that are
identified as crucial because they'll have the most votes.
You're going to list of concerns with
the most votes then on a separate piece of paper or board,
and if it's post-it, it's really helpful because you can just
move them over into another area.
And that really helps then to move the discussion away from all of
the identified reasons and concerns onto the ideas,
reasons, and concerns that the group has agreed are most important to address.
If you used the post-it,
what you can do is have teams placed those post-it up and then do dot voting again.
In which case, you need to make sure that you give them eight stickers, not four.
This will help you, again,
to arrive at identifying those interventions for that particular problem or for
each particular problem that the team thinks are feasible and will result in success.
When the group has identified which interventions they are going to elect to implement,
it's important that a point person,
and perhaps if it's a tough problem,
a team of persons takes responsibility for
ensuring that the interventions that the group agrees should be implemented,
have a leader and are addressed successfully.
Failing to identify who will take responsibility is in
itself a risk to project success and to success of implementing those interventions.
Finally, it's important for the facilitator to
follow up with the group at the end of the exercise to make sure that
everyone is on the same page with respect
to the decisions that have been made as a result of
the pre-mortem exercise and who's going to be
taking responsibility to make sure that those things happen.
It's also important that the quality improvement team needs to
understand that this is not a one and done event.
After the three or four concerns that rose to
the top during this pre-mortem exercise are completed,
the team should go back and review the list of concerns to see if there are items
that weren't considered significant enough at the beginning that now,
they can have time to consider and develop interventions for if they
are considered to be important enough risks that they need to be addressed.
In addition, it's highly likely that
new problems may be occurring or they may be on the horizon and this will
help the team to identify those problems and
figure out interventions that the team should take to address those new issues.
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