Failing by Design: why winter is a season, not a surprise

Failing by Design: why winter is a season, not a surprise

ED Shorter Stays ForumApril 2013

Jane Lawless

ED Shorter Stays ForumApril 2013

Jane Lawless

Definition of a Crisis – A critical event or point of decision which, if not handled in an appropriate and timely manner (or if not handled

at all), may turn into a disaster or catastrophe

Plan Design Execute Impact

Plan Design Execute Impact

Focus of the sessionFocus of the session

Living within the failure boundaries

Organisational resilience and why it matters

The three levels of design – base –buffer – recovery

The Resilience Zones Model

Surviving the ‘Death Zone’

Living within the failure boundaries

Organisational resilience and why it matters

The three levels of design – base –buffer – recovery

The Resilience Zones Model

Surviving the ‘Death Zone’

Unacceptable Workload

Unacceptable outcomes

Financial Failure

ORGANISATIONAL RESILIENCEORGANISATIONAL RESILIENCE

“A property of an organisation that enables it to continue to achieve its objectives under varying conditions, and when major variance occurs to

recover without significant loss.”(Eric Hollnagel)

“A property of an organisation that enables it to continue to achieve its objectives under varying conditions, and when major variance occurs to

recover without significant loss.”(Eric Hollnagel)

• Working within maximum productive capacity

• Addressing the organisational blind spot around the gap between work as imagined and work as it actually happens

• Focusing on studying success in preference to studying failure

• Working within maximum productive capacity

• Addressing the organisational blind spot around the gap between work as imagined and work as it actually happens

• Focusing on studying success in preference to studying failure

The three levels of designing for success

The three levels of designing for success

1. Base design – average service utilisation (volumes) x average hours of care

2. Buffer design – Built in level of redundancy and flexibility to account for known variance range

1. Base design – average service utilisation (volumes) x average hours of care

2. Buffer design – Built in level of redundancy and flexibility to account for known variance range

Production planningProduction planning

July August September

2011 budgeted 109 109 109

2011 actual 117 135 187

2012 budgeted 102 102 102

2012 actual 117 155 148

The three levels of designing for success

The three levels of designing for success

1. Base design – average service utilisation (volumes) x average hours of care

2. Buffer design – Built in level of redundancy and flexibility to account for known variance range

3. Recovery design – harm minimisation when working in a degraded context (the ‘death zone’)

1. Base design – average service utilisation (volumes) x average hours of care

2. Buffer design – Built in level of redundancy and flexibility to account for known variance range

3. Recovery design – harm minimisation when working in a degraded context (the ‘death zone’)

Lawless 2013

Lawless 2013

Lawless 2013

Lawless 2013

Sacrificing decisionsSacrificing decisions• reduce demand (cancel/defer) – affects productivity & volumes

• increase capacity by using unbudgeted resources tagged for future activity (extras, overtime) – impacts financially and on future service provision

• increase capacity by cancelling planned non clinical activity (e.g. education or leave) – impacts on workforce & ultimately service quality

• Require extraordinary work effort

• reduce quality of service

• reduce demand (cancel/defer) – affects productivity & volumes

• increase capacity by using unbudgeted resources tagged for future activity (extras, overtime) – impacts financially and on future service provision

• increase capacity by cancelling planned non clinical activity (e.g. education or leave) – impacts on workforce & ultimately service quality

• Require extraordinary work effort

• reduce quality of service

Impact of sacrificing optionsImpact of sacrificing options• Budget over run• Queuing• Production delays• Service cancellation• Care rationing• Harm/error incidents/adverse events • Poor patient placement• Increased staff discretionary effort (missed breaks/overtime)• Staff fatigue/anxiety or distress• Staff feeling professionally compromised• Avoidable patient deaths

• Budget over run• Queuing• Production delays• Service cancellation• Care rationing• Harm/error incidents/adverse events • Poor patient placement• Increased staff discretionary effort (missed breaks/overtime)• Staff fatigue/anxiety or distress• Staff feeling professionally compromised• Avoidable patient deaths

Lawless 2013

AVOIDABLE HARM

AVOIDABLE DEATH

CANCELLATIONS INCREASED LOS

STAFF OVERTIME

TREATMENT DELAYS

WASTED CAPACITY – UNABLE TO BE REINVESTED

Care Capacity Demand Management: strengthening resilience

Addressing the blind spot

Critical metrics

Smoothing Variance

Smoothing variance & improving staffing design

Variance Response Management: Capacity at a Glance

Event Report

Click on event

Daily report

Care Capacity Demand Manage

ment

CCDM ESSENTIAL METRICS

SAFE SIX IMPACT METRICS

PTS RECEIVING THE FULL PACKAGE OF CARE

FREEDOM FROM HARM

STAFF SATISFACTION WITH THE JOB DONE

WORK EFFORT REASONABLE

PRODUCTIVITY/FLOW/VOLUME TARGETS ACHIEVED ADHERENCE TO BUDGET

Organisational planning, design & resourcing •Forecast demand•Resource matching•Budgeting

Service/Ward Core Data Set

Mix & Match Set base staffing design Set base resource design

Central Operations Management

•Reallocating resources•Adjusting care capacity & demand using Standard Operating Responses

CCDM CouncilMonitors persistent issues with Indicator SetRecommends design changes to organisation

Ward Data Council•Adapts local design and responses•Recommends change to operational design and responses

Service/ Ward Management

•Uses Standard Operating Responses

CARE CAPACITY DEMAND MANAGEMENTCARE CAPACITY DEMAND MANAGEMENT

EVERYDAY VARIAN

CE MAN

AGEM

ENT

REFI

NE

DES

IGN

OVE

R TI

ME

PLANNING AND RESOURCING THE FUTURE

DHB Involvement with CCDM (chronological)DHB Involvement with CCDM (chronological)

Current or past involvement

Bay of PlentyWest CoastNorthlandMidCentralNelson MarlboroughTairawhiti (combined CCDM/RTC)TaranakiSouthern (both sites)WaitemataHutt Valley

Current or past involvement

Bay of PlentyWest CoastNorthlandMidCentralNelson MarlboroughTairawhiti (combined CCDM/RTC)TaranakiSouthern (both sites)WaitemataHutt Valley

Next 12 months confirmedSouth CanterburyWanganuiADHB

Eligible & under discussionWairarapa Hawkes Bay Capital & Coast (planning to be eligible)

Not currently eligibleCounties Manukau (Demonstration site)WaikatoLakesCanterbury

Next 12 months confirmedSouth CanterburyWanganuiADHB

Eligible & under discussionWairarapa Hawkes Bay Capital & Coast (planning to be eligible)

Not currently eligibleCounties Manukau (Demonstration site)WaikatoLakesCanterbury

What does the organisation need to deliver?

SET PRELIMINARY DEMAND FORECAST

What capacity will it take to deliver that?

(CAPACITY MATCH)

Do we have the finances & resource capacity to support

that?

NO

Address the gap

YES

What are we able to do?

RE SET DEMAND FORECAST

-BASE STAFFING MODELLING-(PLANT)-(SUPPLIES)-(SUPPORT INFRASTRUCTURE)

ESTABLISH RESOURCES

DEVELOP & IMPLEMENT PRODUCTION PLAN BASED ON CAPACITY/DEMAND

PROJECTIONS

MONITOR FOR MID RANGE VARIANCE & ACTIVELY REDESIGN

(up to 6 weeks out)

DEAL WITH EMERGENT VARIANCE-Variance smoothing -↑↓ Demand-↑↓Capacity-Redistribute demand or capacity-Make sacrificing decisions

DELIVER SERVICESCOLLECT IMPACT

METRICS

-CAPACITY/DEMAND FORECASTING

-WORKPLACE DESIGN

-DEMAND FLOW