Conducting a Pre-Mortem

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From the course by Johns Hopkins University

Designing for Sustainment: Keeping Improvement Work on Track (Patient Safety IV)

11 оценки

Johns Hopkins University

Designing for Sustainment: Keeping Improvement Work on Track (Patient Safety IV)

11 оценки

Course 4 of 7 in the Specialization Patient Safety

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.

From the lesson

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.

Conducting a Pre-Mortem10:10

Facilitating a Pre-Mortem18:00

Applying Results of a Pre-Mortem14:35

Revisiting the Pre-Mortem8:41

Pre-Mortem Demo Exercise20:13

Meet the Instructors

Lisa H. Lubomski, PhD
Assistant Professor
Department of Anesthesiology and Critical Care Medicine

[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.

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