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www.achse.org.au/frameset.htmlACHSE Victoria Branch
Residential Conference 2003
3 and 4 April
TOWARDS EXCELLENCE IN HEALTH
USING EARLY WARNING SYSTEMS TO IMPROVEPERFORMANCE
“If you can’t see it and measure it, you can’t manage it.”
Facilitator: Associate Professor Jeffrey BraithwaiteCentre for Clinical Governance Research in Health, University of NSW
Residential Conference 2003
Day 1: Thursday 3 April 20038:30 am Arrival, tea and coff ee
9:00 am Opening and welcome A/ Professor J ohn Rasa
President, ACHSE Victorian Branch
The Hon Bronwyn Pike
Minister f or Health
Residential Conference 2003
Day 1: Thursday 3 April 2003
9:15 am I ntroduction and purpose
Who do we have here?
What are our aims?
What are our resources?
What do we think about: Early warning systems?
I mproved perf ormance?
Residential Conference 2003
Day 1: Thursday 3 April 2003
9:30 am Where have we come f rom?
The journey so f ar:
The politics, emotions,achievements, tragedies andfacts about the past
Residential Conference 2003
Day 1: Thursday 3 April 2003
10:30 am Break
Tea and coff ee
See you back here at11:00 am promptly
Residential Conference 2003
Day 1: Thursday 3 April 2003
11:00 am Announcements
Tennis Golf
Dinner lists
Residential Conference 2003
Day 1: Thursday 3 April 2003
11:00 am Where are we now?
Environmental audit:
Major problems and challenges f acing us in our policy and management work
Residential Conference 2003
Day 1: Thursday 3 April 2003
11:00 am [Continued] Where are wenow?
Environmental audit:
Major problems andchallenges f acing us in ourpolicy and management work
Residential Conference 2003
Day 1: Thursday 3 April 2003
12:00 Lunch
Enjoy lunch
Make sure you visit the Sponsors’ area
See you back here at 1:00 pm promptly
Residential Conference 2003
Day 1: Thursday 3 April 2003
1:00 pm The solutions tendered todate
Current ideas on what to do:
Review of materials
Assessment of these
Discussion of their relativemerits in generating solutions
Residential Conference 2003
Day 1: Thursday 3 April 2003
1:00 pm [Continued] The solutionstendered to date
Current ideas on what to do:
Review of materials
Assessment of these
Discussion of their relativemerits in generating solutions
Residential Conference 2003
Day 1: Thursday 3 April 20032:30 pm Voices f rom the experts …
Compere: J ohn Rasa
Panellists: Kathy Byrne
Kath Cook
Anna Fletcher
Shane Solomon
Residential Conference 2003
Day 1: Thursday 3 April 2003
4:00 pm Announcements and closure…
Day one is concluding
Enjoy the evening
Residential Conference 2003
Day 1: Thursday 3 April 2003
Evening sessions
6:30 pm Pre dinner drinks and guestspeaker
7:45 pm Dinner and entertainment
Residential Conference 2003
Day 2: Friday 4 April 2003
8:30 am Recap
What were the take homemessages f rom yesterday?
Where are we at now?
Residential Conference 2003
Day 2: Friday 4 April 2003
8:45 am Case studies
Challenger launch decision
King Edward Hospital
Residential Conference 2003
Day 2: Friday 4 April 2003
8:45 am Case study #1
What are the f acts of the Challenger case?
Residential Conference 2003
Day 2: Friday 4 April 2003
8:45 am Case study #2
What are the f acts of the King Edward Hospital case?
Residential Conference 2003
KEH: key barriers to change
1. Reluctance to admit errors and flaws.
2. Reluctance to adopt a ‘beyond blame’ culture.
3. Reluctance to acknowledge that clinicians are accountable.
Residential Conference 2003
1. Reluctance to admit errors and flaws
review of 372 high risk obstetric cases
47% - one or more clinical errors
Residential Conference 2003
2. Reluctance to adopt a‘beyond blame’ culture
Perinatal Mortality Committee meetings
‘witch hunts’
‘finger pointing exercises’
‘blame culture’
‘intimidating’
‘denigrating’
‘vindictive’
Residential Conference 2003
3. Reluctance to acknowledge that clinicians are accountable
‘Peering in from outside’Poor incident reporting and management
1. ‘Doctor’s Alert’
2. No patient information to
‘management’ without written
authority from the patient
3. No answers to management questions
without prior written notice of question.
Residential Conference 2003
Management
Significance of management: management is crucial to delivery of health care management affects all aspects of the quality
of health care.
Who should manage? the best doctors are not necessarily the best
managers the best managers are not necessarily doctors doctors can’t be in two places and do two jobs at
the same time.
Residential Conference 2003
Day 2: Friday 4 April 2003
8:45 am Analysis of case studies, issues arising:
Culture
Systems
Change management
Organisational learning
Network building
Early warning detection
Residential Conference 2003
Day 2: Friday 4 April 2003
8:45 am Case studies, defi nitions andmodels: Culture
Above the waterline lie the observable workplace behaviours, practices and discourse: this is ‘the way we do things round here’.
Below the waterline lie the underlying beliefs, attitudes, values, philosophies and taken-for-granted aspects of workplace life: ‘why we do the things we do round here’.
Figure 1: the icebergmodel of culture
Residential Conference 2003
Day 2: Friday 4 April 2003
8:45 am Case studies, defi nitions andmodels: Systems
Systems can be hard or sof t
Hard systems – documentedprocesses, computers
Sof t systems – people’sbehaviour, politics, relationships
Residential Conference 2003
Day 2: Friday 4 April 2003
8:45 am Case studies, defi nitions andmodels: Change management
Some core concepts Strategic f ramework f or change,
style of change, scope of change,involving others, innovation journey,communications strategy
Residential Conference 2003
Day 2: Friday 4 April 2003
8:45 am Case studies, defi nitions andmodels: Organisationallearning
Senge’s disciplines – systemsthinking, mental models,personal mastery, teamlearning, shared vision
Residential Conference 2003
Day 2: Friday 4 April 2003
8:45 am Case studies, defi nitions andmodels: Network building The goal is to create a better
networked organisation – issuesinclude risks and costs,stakeholder buy-in, top downversus bottom up, unclear results
Residential Conference 2003
Day 2: Friday 4 April 2003
8:45 am Case studies, defi nitions andmodels: Early warningdetection
Like the canary down themine, what’s the canary inthe system?
Residential Conference 2003
Day 2: Friday 4 April 2003
10:30 am Break
Tea and coff ee
See you back here at11:00 am promptly
Residential Conference 2003
Day 2: Friday 4 April 2003
11:00 am Putting it all together:implementation issues
What do we do now?
I nvolving others
Residential Conference 2003
Day 2: Friday 4 April 2003
11:00 am [Continued] Putting it all together: implementation issues
What do we do now?
I nvolving others
Residential Conference 2003
Day 2: Friday 4 April 2003
11:00 am [Continued] Putting it all together: implementation issues
What do we do now?
I nvolving others
Residential Conference 2003
Day 2: Friday 4 April 2003
12:00 Next steps: identif y solutionsand f uture actions
The journey of a thousandmiles …
The next 90 days
Beyond the next 90 days
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Day 2: Friday 4 April 2003
1:00 pm Wrap up and close
A/ Professor J ohn Rasa
Residential Conference 2003
Day 2: Friday 4 April 2003
1:15 pm Lunch
Thank you f or yourattendance
Bon voyage
See you at a learning set … .