Incident Analysis & Daily Visual Management

4 July 2013FHHR

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 Lunch Afternoon

◦ Daily Visual Management: understand and develop some visuals and skills in using daily visual management in your area

Agenda/Objectives

Incident Analysis

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.

NEW NAME: Safety Alert vs Occurrence

Read over the Safety Alert or Incident Form Volunteer for leader for the activity

Table Activity

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

5 Whys

provided as examples different than the interview questions ask how it impacted the incident

Incident Analysis Guiding Questions

(Taken from the Canadian Incident Analysis Framework, pg 89)

Group Activity – 15 minutes◦ determine what questions you as a

manager/director will need to ask◦ Can you answer the 5 Whys?

Incident Analysis Guiding Questions

Seriousness of the Safety Alert (Classification System)

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. Seriousincident where the potential for litigation is thought to be prevalent.

Tragic incidents where the potential is that litigation could be initiated at anytimeAn unanticipated death or potential major loss of function or major injury,including, but not limited to:

Critical Incident vs Multidisciplinary Event Review vs Informal Review vs Medical Review vs Staff Discussion

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

MoH Safety Alerts

Table Activity – 5 minutes◦ Determine

Code Response required Timeline for reporting

Coding, Reviews and Timelines

Chronological listing of information pertaining to event.

Include:◦ 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

Sequence of Events

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

Fishbone Diagram

Cause and Effect

Table Activity – 20 minutes◦ In your table groups, determine contributing

factors and root causes to complete a fishbone diagram

Fishbone Diagram

Mistake ProofingMike

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

Mistake Proofing

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

Barriers to Mistake Proofing

Inspection Standard Work Visual Control Devices

Basic Elements of Mistake Proofing

Inspection

Standard Work is a set of specific instructions that allow processes to be completed in a consistent, timely, and repeatable manner.

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.

Standard Work

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

Benefits of Standard Work

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

Visual Control

Clear guidelines for use Management leadership during

implementation and use Prompt response Standardized and clear responses

Visual Control Requirements

Devices

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

Key features of effective actions

Table Activity◦ Develop Action Plan◦ Action Plan ‘must haves’:

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

Actions and Mistake Proofing

Daily Visual Management

Daily Management enables us to understand current day-to-day activities.

Using DVM as Coaching Opportunity

Kyle

Lunch

Tour of Walls

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!

Daily Management Consists of:

What’s on the Walls

Work Standard

Set-up Wall Walk Content of Wall Corrective Actions

Visibility Wall Score Tool

Checklist

QCDSMBetter Care

Better Teams

Better Value

Better Health

• Quality• Cost• Delivery• Safety• Morale

Basic ElementsStuart

Visual Daily Management

OverviewWhat 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”?

Attendance Management Metrics Sick Time 2 methods for visualising and managing sick

time in your department

1. Sick Leave Cross2. 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...

Sick Leave Cross

Sick Leave Cross 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.

Weekly SL Departmental Report

Weekly Departmental Report 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. Please contact the Attendance Support Consultant (Donna

Watson) for assistance with creating an attendance support strategy for your work area.

Wage Driven Premium Metrics Wage Driven Premium (WDP)

◦ Overtime◦ Call Back

Currently HR is providing one tool to assist teams in managing and identifying trends in their WDP usage.◦ Weekly Departmental Averaging Report

This tool is also usually displayed under the “COST” heading in the Q-C-D-S-M model.

Weekly WDP Departmental Report

Weekly WDP Departmental Report 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 replacement2. 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.

Workplace Safety (Staff) Metrics Tracking incidents & occurrences related to

staff safety.◦ Patient safety occurrences should also be tracked in

appropriate areas, typically using the safety cross. Departments should be currently using 2

tools to track and discuss workplace safety.1. Staff Safety Cross2. Weekly Regional Report

Staff Safety reporting should be displayed under the “SAFETY” heading of the Q-C-D-S-M model

Staff Safety Cross

Staff Safety Cross

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.

Weekly Regional Report

Weekly Regional Report 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.

What do I track under Morale? 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)

We would recommend that most areas would also include the following concepts under Morale...

What do I track under Morale? “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.

What do I track under Morale? 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.

What do I track under Morale?

What do I track under Morale?“PICK”

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)

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.

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)

Unique Elements

Pulling it all togetherKyle

Wrap -UpStuart

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

References