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

1. Failing by Design: why winter is a season, not a surprise ED Shorter Stays Forum April 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

3. Design Design Plan Plan Execute Execute Impact Impact

5. Focus 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’

6. Unacceptable outcomes Unacceptable Workload QUALITY WORK ENVIRONMENT QUALITY PATIENT CARE Financial Failure BEST USE OF HEALTH RESOURCES

7. ORGANISATIONAL 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)

8. 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

9. The three levels of designing for success • Base design – average service utilisation (volumes) x average hours of care • Buffer design – Built in level of redundancy and flexibility to account for known variance range

10. Production planning

11. The three levels of designing for success • Base design – average service utilisation (volumes) x average hours of care • Buffer design – Built in level of redundancy and flexibility to account for known variance range • Recovery design – harm minimisation when working in a degraded context (the ‘death zone’)

12. Organisational Resilience – Ideal Zone Lawless 2013

13. Buffer Zones Lawless 2013

14. Recovery Zones Lawless 2013

15. Organisational Resilience - Zones Lawless 2013

16. Sacrificing 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

17. Impact 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

24. Organisational Resilience - Zones INCREASED LOS TREATMENT DELAYS CANCELLATIONS AVOIDABLE DEATH AVOIDABLE HARM STAFF OVERTIME WASTED CAPACITY – UNABLE TO BE REINVESTED Lawless 2013

25. Care Capacity Demand Management: strengthening resilience Smoothing Variance Addressing the blind spot Critical metrics

26. Smoothing variance & improving staffing design

27. Variance Response Management: Capacity at a Glance

28. Event Report

29. Daily report Click on event

30. 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 QUALITY WORK ENVIRONMENT QUALITY PATIENT CARE Care Capacity Demand Management BEST USE OF HEALTH RESOURCES • PRODUCTIVITY/FLOW/VOLUME TARGETS ACHIEVED • ADHERENCE TO BUDGET

31. PLANNING AND RESOURCING THE FUTURE • Organisational planning, design & resourcing • Forecast demand • Resource matching • Budgeting • Central Operations Management • Reallocating resources • Adjusting care capacity & demand using Standard Operating Responses CCDM Council Monitors persistent issues with Indicator Set Recommends design changes to organisation Service/Ward Core Data Set EVERYDAY VARIANCE MANAGEMENT REFINE DESIGN OVER TIME • Ward Data Council • Adapts local design and responses • Recommends change to operational design and responses • Service/ Ward Management • Uses Standard Operating Responses Mix & Match Set base staffing design Set base resource design CARE CAPACITY DEMAND MANAGEMENT

33. DHB Involvement with CCDM (chronological) Current or past involvement • Bay of Plenty • West Coast • Northland • MidCentral • Nelson Marlborough • Tairawhiti (combined CCDM/RTC) • Taranaki • Southern (both sites) • Waitemata • Hutt Valley Next 12 months confirmed • South Canterbury • Wanganui • ADHB Eligible & under discussion • Wairarapa • Hawkes Bay • Capital & Coast (planning to be eligible) Not currently eligible • Counties Manukau (Demonstration site) • Waikato • Lakes • Canterbury

34. What does the organisation need to deliver? SET PRELIMINARY DEMAND FORECAST -BASE STAFFING MODELLING -(PLANT) -(SUPPLIES) -(SUPPORT INFRASTRUCTURE) What capacity will it take to deliver that? (CAPACITY MATCH) What are we able to do? RE SET DEMAND FORECAST Do we have the finances & resource capacity to support that? NO Address the gap YES -CAPACITY/DEMAND FORECASTING -WORKPLACE DESIGN -DEMAND FLOW ESTABLISH RESOURCES DEVELOP & IMPLEMENT PRODUCTION PLAN BASED ON CAPACITY/DEMAND PROJECTIONS DEAL WITH EMERGENT VARIANCE -Variance smoothing -↑↓ Demand -↑↓Capacity -Redistribute demand or capacity -Make sacrificing decisions MONITOR FOR MID RANGE VARIANCE & ACTIVELY REDESIGN (up to 6 weeks out) COLLECT IMPACT METRICS DELIVER SERVICES