Hello and thank you for watching this video. During this video, we're going to talk about revisiting the pre-mortem exercise. Following the conduct of a pre-mortem exercise, it's important that the quality improvement team understands that they are responsible for working on the interventions they identified and that the team should regularly review something like the pre-mortem results list at their regular meetings, so that they're sensitizing themselves to new issues that are arising and also that they are moving down their list to understand whether new issues that they had not addressed earlier are now becoming important and may pose a risk to project success. The result of the pre-mortem can really be used across all the three phases of a project that I'm going to discuss in this lesson. Early in the project, it can be used to address the two or three items of greatest concern that have been selected from a list generated from the group exercise of the pre-mortem. Once those issues are addressed, the team should schedule additional time to address the remaining items that are on the list that may not have risen to the top during the initial pre-mortem as posing crucial risk to be addressed at that time but that are now becoming important. It's also important that the team leadership in particular manages to keep interventions on track. What I mean by that is that at the end of the pre-mortem exercise, the team should have worked out an action plan for how they would implement the interventions that they had identified to address the two or three items of greatest concern. By determining what will be done, how it will be done, who's going to take responsibility for ensuring that it is done, and then setting a timeline for that work to begin and be completed, this allows the team to really understand what progress is being made and to take steps to set something back on track, provide additional resources, or rethink the timeline if an intervention is not being implemented as expected. Mid-project, the pre-mortem results can be used to, A, evaluate the success of the initial pre-mortem interventions. Did you achieve success in mitigating the risks and barriers that were identified as being really important at the beginning? As I said, previously identifying target additional issues. So, are there remaining issues on the list that are now posing a threat or are there issues that are rising? It's important to understand that mid-project, teams can get complacent. Especially if the project is going well and project leadership kind of backs off on their overview of how the frontline staff is functioning, what the implementation process really looks like. Teams are where if you step back and they may, even without meaning to do so, slide back into doing work the way they used to do it as opposed to doing work the way you want them to do it. So, it's important that teams not get complacent but rather that you may not need to be as keenly focused as you were in the beginning, but mid-project, you still need to maintain a focus on how the work is being done, so that you identify any backsliding or risks to sustaining gains or developing gains that may occur. Sustainment is what a team does to continue to build on the success it's achieved. So, quality improvement projects are undertaken to make positive changes in the way that we're providing care. So we want to achieve success but we want to build on the success that we achieve. Sustainment is understanding how the efforts that you're undertaking to change patient safety culture and to improve safety, persist even after the project is over. It's also when you apply the knowledge that you've gained through a quality improvement project to new challenges. Those can be new challenges, new problems in your clinical area, or they can be helping the team in another clinical area to implement the intervention that you have just successfully implemented again using that knowledge you've gained. So that's what we mean when we talk about sustainment. So late in the project, the pre-mortem can be used to identify, have new problems arisen? Especially problems that are going to affect your team's ability to sustain. Some of these might be things like competing priorities, organizational changes, staff turnover. All three of these things frequently affect projects in the implementation phase because they, unfortunately, are frequent occurrences in healthcare. You can identify and target additional issues from a pre-mortem exercise that's focused on sustaining the gains rather than the pre-mortem exercise that's done at the beginning of a project to identify risks to project implementation. Often, during the sustainment phase, teams gain a new knowledge of the threats to sustainment by completing a second pre-mortem exercise that's focused on identifying issues to be addressed that will result in the team backsliding again. All of the hard work that has been done by the frontline staff and the quality improvement team coming to not because those gains have slipped away. The United Kingdom National Health Service looked at a number of the quality improvement projects that have been undertaken by National Health Service teams and found that as much as one-third of those successful interventions had, within a year, slipped away and the teams were back to doing things the way they'd been done before the implementation. So during sustainment then, doing a pre-mortem can help you to identify those issues. Instead of asking it's a year in the future and the project has failed, some questions you might think about are, what if the team's gains in technical and adaptive work have slipped away? Team members are asked to list all the reasons they can that would result in the loss of the gains that have been made during project implementation. As with pre-mortem during the planning phase, the team then can focus on the top three or four reasons and develop interventions to mitigate the risks that those reasons have to project sustainment. I suggest that as you're undertaking a quality improvement project and you come to the end of that project that you and your team consider completing a pre-mortem exercise so that you can continue to benefit from the goals that you've made during your quality improvement, that you can continue to provide high level evidence-based safe care for your patients, and so that you can learn what it takes to solve problems in the clinical environment in a way that sustains those goals and helps you and your team and other teams to learn from the knowledge that you've gained and spread good work throughout your hospital, throughout your health system, and hopefully, around the world.
