What can go wrong will… Unless you identify potential failures first

Using pre-mortems to make better decisions.

Have you ever imagined a project or initiative failing? This is a difficult thing for most of us to do. Rather, we prefer to think about how projects or initiatives will succeed and so we should. Optimism is good! However, what if by imaging failure, or suboptimal outcomes, you could make better decisions?  What if there was evidence that by identifying reasons for project failures BEFORE they occur? Well there is evidence. And this strategy is called a “pre-mortem”. A well-described, but probably under utilized decision-making approach described by Gary Klein. https://hbr.org/2007/09/performing-a-project-premortem

It’s important to distinguish this from going through the thought process about what “might” happen. Rather it’s critical that team imagines that a bad outcome or project failure DID occur. Then the team comes together to review and generate reasons for the project’s failure. 

This approach can be coupled with simulation by recreating imagined failures. This helps engage the team in the emotions, the decision-making process and the ultimate outcome that resulted in the failure. By understanding and exploring these potential failures, changes can be made and decisions can be altered to mitigate poor outcomes. 

What this looks like in healthcare design

Let’s take the example of the construction of a new healthcare facility. In most situations, it’s not until clinical care begins that potential issues or failures manifest. While the existing process does function to fix problems, there are too often built-in design flaws because they weren’t fully imagined. E.g. poor sightlines to sick patients, lack of space for essential equipment or communication issues in/out of rooms…an issue that has manifested particularly during the pandemic.  A pre-mortem integrated with the simulation-informed design process can help guard against these issues and ultimately result in better outcomes like improved patient care, reductions in adverse events or construction related cost savings/future cost avoidance. 

Imagine a new way forward

Imagine the design and construction of a new in-patient unit. While the clinical and design teams are optimistic the new designs will result in better staff workflows and patient outcomes, there’s inherently some uncertainty that everything will go as planned. The team undertakes a premortem combined with simulation informed design (SID). The clinical & design teams develop a list of potential failures/adverse events before plans are finalized. E.g. a patient who falls moving from the bed to the washroom, a patient suffers cardiac arrest, a substantial construction delay to move into the new clinical space. Then they conduct table top simulations and mock-up simulations of these events followed by expert led debriefings to better understand why these events occurred and solutions to mitigate them. The end result is that the clinical and design teams were able to adjust plans to overcome these failure event BEFORE they ever happen. 

A premortem coupled with SID offers an informed look towards the future. This process offers all the upsides of knowing the future without the downsides of having to go through the actual failures. Don’t we all want to sidestep costly decisions and processes that might result lead to harm? 

Don’t think you have it right, know that you do. 

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