Transcript Title

4 July 2013
FHHR
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Morning
◦ Incident Analysis: introduce tools to assist with the
review of events (near miss or actual) and
determine system changes
◦ Start on Daily Visual Management
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Lunch
Afternoon
◦ Daily Visual Management: understand and develop
some visuals and skills in using daily visual
management in your area
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Occurrence:
◦ noun something that happens; event; incident
Alert:
◦ adjective fully aware and attentive; wide-awake; keen
◦ noun: an attitude of vigilance, readiness, or caution; a
warning or alarm of an impending military attack, a storm,
etc.; the period during which such a warning or alarm is in
effect.
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Read over the Safety Alert or Incident Form
Volunteer for leader for the activity
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Used to move past symptoms and help find
root cause of a problem
Asking “WHY” 5 or more times helps to delve
deep enough to get to the root cause &
understand it
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provided as examples
different than the interview questions
ask how it impacted the incident
(Taken from the Canadian Incident Analysis Framework, pg 89)
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Group Activity – 15 minutes
◦ determine what questions you as a
manager/director will need to ask
◦ Can you answer the 5 Whys?
Code 1
Code 2
Code 3
Code 4
No known injury.
No clinical
significance. No
damage to
equipment or
facility.
Minor injury
requiring basic
first aid or short
term monitoring.
Action to rectify
Adverse outcome
or significant
potential for
adverse outcome.
Insurance claim
anticipated. Root
cause analysis of
system failure is
expected. Serious
incident where the
potential for
litigation is
thought to be
prevalent.
Tragic incidents
where the
potential is that
litigation could be
initiated at
anytime
An unanticipated
death or potential
major loss of
function or major
injury,
including, but not
limited to:
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Critical Incident vs
Multidisciplinary Event Review vs
Informal Review vs
Medical Review vs
Staff Discussion
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The Provincial QCC
reviews all critical
incidents and when
system change is
possible , they send the
alert out to all the RHA
which tells the story and
recommends actions to
take
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Table Activity – 5 minutes
◦ Determine
 Code
 Response required
 Timeline for reporting
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Chronological listing of information pertaining to
event.
Include:
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Date
Day of Week
Time
Information
Source of Information
This can be shown in a table or timeline
Table Activity – 20 minutes
◦ In your table group, write out the sequence of events
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Cause and Effect Diagrams are used when
you have a focused problem to identify all
potential causes to that problem.
A Cause and Effect Diagram will provide:
◦ An easy, structured way to identify all possible causes
◦ An organized view of all possible causes
◦ Understanding of the relationships among the possible
causes
◦ Differentiation of ‘root cause’ from perceived cause
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Fishbone Diagram
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Table Activity – 20 minutes
◦ In your table groups, determine contributing factors
and root causes to complete a fishbone diagram
Mike
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Mistake-prone situations
◦ People Issues: multi-tasking, inexperienced, use of
workarounds, misunderstandings, infrequent task
◦ Product Issues: new product, poor design, changes
to existing products
◦ System or process Issues: new process, unreliable
process, work instructions not immediately
available
◦ Environmental Issues: inadequately maintained
equipment, same information in multiple places,
disorganized and unsafe work spaces
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Inability to envision defect-free work
Failure to recognize defects
Acceptance of defects as part of every day life
Lack of management presence or response to
defects
Fatigue and apathy
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Inspection
Standard Work
Visual Control
Devices
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Standard Work is a set of specific instructions
that allow processes to be completed in a
consistent, timely, and repeatable manner.
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Purpose:
◦ To ensure work and expectations are safe and
reasonable.
◦ To define and standardize normal conditions in
order to see abnormal conditions as soon as they
occur.
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Allow work to be done in the best way, every
time
Allows us to see waste
It is the foundation for improvements
Ensure improvements are held
Assists with training
Specifies responsibility and expected time for
completion
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Learn to distinguish promptly between what
is normal and what is not with visual controls.
Visual Control leads to management by
everyone since problems and actions are
made visible and team-based. Everyone
knows when there is a problem and what to
do about it
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Clear guidelines for use
Management leadership during
implementation and use
Prompt response
Standardized and clear responses
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Address the risks
Utilize the most effective solution
Long term solution
Write in ‘SMART’ format
Right level of system
Responsibility at the right level
Greater positive impact
Based on evidence
Provide enough context
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Table Activity
◦ Develop Action Plan
◦ Action Plan ‘must haves’:
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System or process change
Describe what action is to take place
Lead person responsible to ensure action is taken
Date for action to be completed
Daily Management enables us to understand
current day-to-day activities.
Kyle
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A Visual Workplace where abnormalities are
seen.
An environment where staff test their own
ideas.
Transparency of objectives and metrics.
Managing by measures that change regularly.
What you cannot see, you cannot manage!
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Set-up
Wall Walk
Content of Wall
Corrective Actions
QCDSM
Better Health
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Quality
Cost
Delivery
Safety
Morale
Better Care
Better Teams
Better Value
Stuart
Overview
-What are the basic elements of a “Viz Wall”?
-Why are we interested in these elements?
-What am I looking at?
-What are the key messages I want to
communicate to my staff about these metrics?
- What do I track under “Morale”?
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Sick Time
2 methods for visualising and managing sick
time in your department
1. Sick Leave Cross
2. Weekly Departmental Averaging Report (from HR)
These tools are usually displayed under the
“COST” heading in the Q-C-D-S-M model.
Now lets look at these visuals a little closer...
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It is a daily management tool to be updated
every day during the daily huddle.
This tool allows the manager to plan for the
day and may help to predict any potential
workload or safety issues and action plan
accordingly.
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Is a weekly management tool.
Should be discussed generally with teams weekly as updated.
Shows how the department is trending over a period of time.
Communicate the following...
◦ Above/below regional target
◦ If below or trending downward, don’t be afraid to celebrate
this and congratulate the team on good performance.
◦ If significantly above or regularly trending upwards,
highlight the impact that this has on operations.
 Highlight the cost to the department in sick time costs or
potential costs like OT replacement.
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Please contact the Attendance Support Consultant (Donna
Watson) for assistance with creating an attendance support
strategy for your work area.
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Wage Driven Premium (WDP)
◦ Overtime
◦ Call Back
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Currently HR is providing one tool to assist
teams in managing and identifying trends in
their WDP usage.
◦ Weekly Departmental Averaging Report
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This tool is also usually displayed under the
“COST” heading in the Q-C-D-S-M model.
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Is a weekly management tool
Should be discussed generally with teams weekly as updated.
Shows the manager how the department is trending over a period of time.
The biggest contributors to WDP are:
1.
Vacation replacement
2.
Sick Leave
3.
General Leaves of Absence
You want to communicate to your team the following main points/concepts.
◦ We are above/below regional target
◦ If below or trending downward, don’t be afraid to celebrate this and
congratulate the team on good performance.
◦ If significantly above or regularly trending upwards, highlight the impact
that this has on operations.
◦ If your department has a high instance of OT use, consider performing a
regular review and evaluation of your Overtime approval criteria with your
senior leader as well as ensuring that your departmental vacation is
managed in such a way that the department is not placed in a potential OT
liability situation.
To assist with management of OT, Labour Relations and Attendance Support
are working on an Overtime Approval protocol which will be rolled out to
Managers by early Fall.
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Tracking incidents & occurrences related to
staff safety.
◦ Patient safety occurrences should also be tracked in
appropriate areas, typically using the safety cross.
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Departments should be currently using 2
tools to track and discuss workplace safety.
1. Staff Safety Cross
2. Weekly Regional Report
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Staff Safety reporting should be displayed
under the “SAFETY” heading of the Q-C-DS-M model
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is a daily management tool to
be updated every day during the
daily huddle.
 This tool allows the manager to
plan for the day and may help to
predict any potential workload or
safety issues and action plan
accordingly.
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Regional staff safety metrics are provided to all
departments for information purposes.
Service Line metrics will be made available
shortly.
Data includes any incident for which there was a
time loss. It does not take into account any
subsequent WCB adjudication for or against the
submitted claim.
HR is looking for ways to share learnings and
action plans across the organization (“yokoten”)
to enable departments with potential for similar
occurrences to mitigate their risk.
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This is something that a lot of departments
and organizations struggle at defining and
tracking.
HR is working on providing some standard
data for departmental “Viz Walls”
◦ Certification completion rates (TLR, PART, HH, KB &
more) – easy to measure and to impact
performance.
◦ Engagement Survey (scores and ongoing
measurement)
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We would recommend that most areas would
also include the following concepts under
Morale...
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“Safety Nods” – recognition of staff who identify a potential staff or
patient safety issue and potential resolution to the issue.
Recognition may include a photo and brief description of the issue.
Birthday Wall – a quick and easy way to ensure that peoples
birthdays are recognized and celebrated.
Customer Satisfaction scores – scores available on
www.qualityinsight.ca
“Safety Talk” – start each huddle with a discussion on safety.
Although managers should lead this for the most part, this
responsibility can also be rotated through your staff. Staff members
can include examples of staff safety observations, patient safety and
even everyday observations. This is another step on the path to
safety as a culture, Stop the Line and getting people used to talking
about safety issues in a “don't blame/don’t judge” atmosphere.
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Staff Innovation
◦ Create a tool for receiving and evaluating staff kaizen/improvement ideas.
 Thedacare uses the “PICK” matrix which focuses on categorizing staff
ideas based on a “return on investment” philosophy. If something is low
cost/high return then it should be pursued. High cost/low return are
eliminated and anything in between requires further conversation. (see
further slides)
 Virginia Mason uses “ELI” (Everyday Lean Ideas) which follows a similar
process of prioritization and implementation.
◦ While KPO finalizes the tool/process for managers and staff of Five Hills,
please do not wait to implement your own system for capturing staff ideas
and regularly discussing their value at the team huddles. Ideas should be
implemented to encourage more ideas. However prior to implementing
any ideas, conversations should occur with your Senior Leader.
◦ For a metric on Morale you can always start by tracking the number of
improvement ideas received. The number of ideas received indicates (at a
high level) an engaged, happy workforce.
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This tool, developed by Lockheed Martin, is to assist with organizing process
improvement ideas and categorizing them. It is also a powerful and simple
decision support tool.
It helps you quickly decide what is the most beneficial option in terms of
Highest Payoff for Least Effort.
When faced with multiple improvement ideas or options it may be used to
determine the most useful. There are four categories on a 2 by 2 matrix;
horizontal is scale of payoff (or benefits), vertical is ease of implementation.
By deciding where an idea or decision option falls on the chart four proposed
project actions or decisions are provided; Possible, Implement, Challenge
and Kill (thus the name PICK).
◦ Possible - Low Payoff, Easy to do (low cost)
◦ Implement - High Payoff, Easy to do (low cost)
◦ Challenge - High Payoff, Hard to do so challenge it to see if there is an easier way
e.g. break down the solution into smaller components (high cost)
◦ Kill Low Payoff, Hard to do (high cost)
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The vertical axis, representing ease of implementation would typically
include some assessment of cost to implement as well.
Talk to your Senior Leader about implementing this tool in your work area today.
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Activity - May work in table group or as
individuals depending on your area
◦ This is your opportunity to decide on metrics for
your wall.
◦ Complete the graph for the metric
◦ Complete the Checklist (in handout)
Kyle
Stuart
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Standard Operations Module 11, JBA
Visual Control Module 10, JBA
Mistake Proofing Workshop, Virginia Mason
Medical Center
Canadian Incident Analysis Framework, CPSI
World Class Management System Module 21,
JBA