Failing by Design: why winter is a season, not a surprise ED Shorter Stays Forum April 2013 Jane Lawless 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

Plan Design ExecuteImpact Plan Design ExecuteImpact Plan Design ExecuteImpact

PlanDesignExecuteImpactReview

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’  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 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 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 planning JulyAugustSeptember 2011 budgeted actual budgeted actual

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’)

Critical Zone Degraded Zone Stretch Zone Ideal Operating Zone Lawless 2013 Sub-productive Unproductive

Critical Zone Degraded Zone Stretch Zone Ideal Operating Zone Lawless 2013 Sub-productive Unproductive

Critical Zone Degraded Zone Stretch Zone Ideal Operating Zone Lawless 2013 Sub-productive Unproductive

Critical Zone Degraded Zone Stretch Zone Ideal Operating Zone Lawless 2013 Sub-productive Unproductive

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 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 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

Death Zone

Critical Zone Degraded Zone Stretch Zone Ideal Operating Zone Lawless 2013 Sub-productive Unproductive AVOIDABLE HARM AVOIDABLE DEATH CANCELLATIONS INCREASED LOS STAFF OVERTIME TREATMENT DELAYS WASTED CAPACITY – UNABLE TO BE REINVESTED

Care Capacity Demand Management: strengthening resilience Base staffing design Base & buffer Responding to variance Recovery planning Addressing the blind spot Critical metrics 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 Management CCDM ESSENTIAL METRICS SAFE SIX IMPACT METRICS 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 Organisational planning, design & resourcing Forecast demand Resource matching Budgeting Service/Ward Core Data Set Mix & Match Set base staffing design Set base resource design Mix & Match Set base staffing design Set base resource design Central Operations Management Reallocating resources Adjusting care capacity & demand using Standard Operating Responses 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 CCDM Council Monitors persistent issues with Indicator Set Recommends design changes to organisation Ward Data Council Adapts local design and responses Recommends change to operational design and responses Ward Data Council Adapts local design and responses Recommends change to operational design and responses Service/ Ward Management Uses Standard Operating Responses Service/ Ward Management Uses Standard Operating Responses CARE CAPACITY DEMAND MANAGEMENT EVERYDAY VARIANCE MANAGEMENT REFINE DESIGN OVER TIME PLANNING AND RESOURCING THE FUTURE

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 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 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

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 SERVICES COLLECT IMPACT METRICS -CAPACITY/DEMAND FORECASTING -WORKPLACE DESIGN -DEMAND FLOW