Incident Analysis & Daily Visual Management

1. Incident Analysis & Daily Visual Management 4 July 2013 FHHR

2. Agenda/Objectives • 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

3. Incident Analysis

4. NEW NAME: Safety Alert vs Occurrence • Occurrence: • nounsomething 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.

6. Table Activity • Read over the Safety Alert or Incident Form • Volunteer for leader for the activity

7. 5 Whys • 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

8. Incident Analysis Guiding Questions • provided as examples • different than the interview questions • ask how it impacted the incident (Taken from the Canadian Incident Analysis Framework, pg 89)

9. Incident Analysis Guiding Questions • Group Activity – 15 minutes • determine what questions you as a manager/director will need to ask • Can you answer the 5 Whys?

10. Seriousness of the Safety Alert (Classification System)

12. Critical Incident vs • Multidisciplinary Event Review vs • Informal Review vs • Medical Review vs • Staff Discussion

14. MoH Safety Alerts • 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

15. Coding, Reviews and Timelines • Table Activity – 5 minutes • Determine • Code • Response required • Timeline for reporting

16. Sequence of Events • 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

17. Cause and Effect • 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

18. Fishbone Diagram • Table Activity – 20 minutes • In your table groups, determine contributing factors and root causes to complete a fishbone diagram

19. Mistake Proofing Mike

20. Mistake Proofing • 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

21. Barriers to 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

22. Basic Elements of Mistake Proofing • Inspection • Standard Work • Visual Control • Devices

23. Inspection

24. Standard Work • 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.

25. Benefits of 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

26. Visual Control • 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

29. Visual Control Requirements • Clear guidelines for use • Management leadership during implementation and use • Prompt response • Standardized and clear responses

30. Devices

31. Key features of effective actions • 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

32. Actions and Mistake Proofing • TableActivity • 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

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

34. Using DVM as Coaching Opportunity Kyle

35. Lunch

36. Tour of Walls

37. Daily Management Consists of: • 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!

38. What’s on the Walls

39. Work Standard

41. Visibility Wall Score Tool • Set-up • Wall Walk • Content of Wall • Corrective Actions

42. Checklist

43. QCDSM Better Health Better Care Better Teams Better Value • Quality • Cost • Delivery • Safety • Morale

44. Basic Elements Stuart

45. Visual Daily Management 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”?

46. Attendance Management Metrics • Sick Time • 2 methods for visualising and managing sick time in your department • Sick Leave Cross • 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...

47. Sick Leave Cross

48. 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.

49. Weekly SL Departmental Report

50. 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.