[MUSIC] Most of the work that I do involves helping teams to improve patient safety and the delivery of evidence-based care through large-scale collaborative projects. Today, I'm going to talk to you about a very powerful tool called the Pre-Mortem Exercise that teams can use to identify barriers and challenges to project success before the project is implemented. After viewing this lesson, students should be able to describe the steps of the Pre-Mortem Exercise, summarize the results of the Pre-Mortem, apply the results of a Pre-Mortem Exercise to mitigate risks to project implementation, prepare for project sustainment by revisiting risks to project sustainability that were identified in the Pre-Mortem Exercise. Let's get started. In the late 1990s, the US Institute of Medicine convened a panel to take a hard look at the quality of healthcare delivery in the United States healthcare system. That panel resulted in the publication of two sentinel works, To Err Is Human and Crossing the Quality Chasm. Both of these works outlined the nature of the problem affecting the delivery of high quality care in the US health system and suggested solutions to those problems so that it would improve the healthcare delivery in the United States. In the crossing the quality chasm, the difference in quality between the ideal healthcare delivery and the actual healthcare delivery in the United States healthcare system was defined as a chasm. As a result of this and other work, many hospitals and health systems in the United States began to undertake, and continue to do so today, quality improvement projects aimed at providing patients with safe and high quality, evidence-based care. Achieving success, however, is easier said than done. Unfortunately, given the time, resources, and money devoted to these efforts, research has shown us that two-thirds of quality improvement implementations result in failure. A study that was done in the National Health Service in the United Kingdom found that one-third of all projects that achieved their goals were unable to sustain their improvements a year after the project ended. No one starts a project hoping to fail. So what does it take to ensure that projects that are started achieve the results that are desired and are able to sustain those results once the formal project has ended? One way to do this is to identify the barriers and challenges to project implementation before the project starts rather than after the project starts. The Pre-Mortem Exercise is one tool that allows teams to do this. Within any healthcare team, or any work team at all, every member of that team has an idea of what the barriers and challenges are to any work implementation or any work project that they're doing. But unfortunately, members of work teams are often not comfortable speaking up to voice their concerns when they're made. This prevents project teams and others from benefiting from the wisdom and the knowledge within those healthcare team members that would help prevent problems down the road. In order for this to happen, we need to create environments where it's safe for people to speak up and voice their concerns. But we also need leaders who are willing to listen and implement suggestions that may reasonably decrease the chance or mitigate the risk of barriers and challenges. The Pre-Mortem is a tool that can make that happen. The Pre-Mortem was developed by Gary Klein and his colleagues as a means of helping teams to do this early identification of barriers and challenges. To think about the Pre-Mortem best, it may be better to think about the postmortem. A postmortem is an autopsy that's performed after a patient has died. While it can be very helpful to the doctors who want to understand how that patient died and to others who may be concerned to answer that same question, it really doesn't do very much to help the patient who's the central actor in this event. The Pre-Mortem can be used to identify potential barriers and vulnerabilities to project success before they occur. It also helps to build intuition about and sensitivity to future problems that might occur during the implementation phase or during the sustainability phase of a project when the project has successfully gotten off the ground but may be subject to risks from emerging or, shall we say, later developing project problems that may occur. Far too often, the reasons for quality improvement project failure are not identified until after the project is over. Just as the postmortem, it's not very helpful to the patient, but it's extremely helpful to doctors and others who want to understand why a patient died. Understanding the reasons for project failure can be helpful to future projects, but they don't do very much to help the project while it was ongoing. Using a technique called prospective hindsight, the Pre-Mortem asks team members to imagine that the project has failed, to brainstorm and identify reasons for project failure, and develop plans that might help mitigate these barriers and achieve project success. The Pre-Mortem is a four-step exercise. In step 1, members of the team are asked to imagine that it's one year into the future. That's the perspective hindsight part. And despite all of the team's effort, the project has failed catastrophically. Things have gone completely wrong on a number of fronts. And the project is just totally off the rails. The team participating in the exercise is asked to imagine what for them does that worst case scenario look like. Next, members are asked to spend about ten minutes generating reasons for failure and writing down all the reasons that they believe this failure could have occurred. So we're asking the central question of, what could have caused our project to fail? In step 3, team members are asked to prioritize the list of potential reasons for failure. They then address the top two or three items from the list that are of greatest concern or pose the greatest risk to project failure. And they work together to develop specific action plans they can take to avoid or manage the issues that have been raised and agreed upon as important enough to pursue. Teams can use a scale like this one here to identify their level of concern for the issues that they've raised on their own individual list and then the issues that are raised on the total list generated from the input of all members participating in the Pre-Mortem Exercise. In step 4, teams are reminded that this is not a one and done effort. And throughout the project, it's important to periodically review the potential problem list. Those two or three items that the team agrees to approach and address in the initial project planning phase, once they're resolved, other issues may raise their heads. There are other issues on the list that now should be tackled because the bigger ones are out of the way. And so at the usual team meetings, it's important periodically to review this list. Reviewing the list sensitizes the team to problems that may be emerging, helps them to identify possible interventions to those new problems, and then put those interventions in place to really help achieve project success. So in summary, for the Pre-Mortem Exercise, step 1 is asking the team one year out to imagine what the worst case scenario for failure looks like. In step 2, the team is asked to generate a list of the reasons that the project could have failed. In step 3, the team then works together to identify specific actions they can take to manage or avoid two or three of the most important issues placing the project at risk. And then in step 4, periodically reviewing and resensitizing themselves to potential problems that may occur throughout the project and at the point of project sustainability.
