achse.au/frameset.html achse victoria branch

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


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


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?



9:30 am Where have we come f rom?

The journey so f ar:

The politics, emotions,achievements, tragedies andfacts about the past



10:30 am Break

Tea and coff ee

See you back here at11:00 am promptly



11:00 am Announcements

Tennis Golf

Dinner lists



11:00 am Where are we now?

Environmental audit:

Major problems and challenges f acing us in our policy and management work



11:00 am [Continued] Where are wenow?

Environmental audit:

Major problems andchallenges f acing us in ourpolicy and management work



12:00 Lunch

Enjoy lunch

Make sure you visit the Sponsors’ area

See you back here at 1:00 pm promptly



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



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


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



4:00 pm Announcements and closure…

Day one is concluding

Enjoy the evening



Evening sessions

6:30 pm Pre dinner drinks and guestspeaker

7:45 pm Dinner and entertainment


Day 2: Friday 4 April 2003

8:30 am Recap

What were the take homemessages f rom yesterday?

Where are we at now?



8:45 am Case studies

Challenger launch decision

King Edward Hospital



8:45 am Case study #1

What are the f acts of the Challenger case?



8:45 am Case study #2

What are the f acts of the King Edward Hospital case?


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.


1. Reluctance to admit errors and flaws

review of 372 high risk obstetric cases

47% - one or more clinical errors


2. Reluctance to adopt a‘beyond blame’ culture

Perinatal Mortality Committee meetings

‘witch hunts’

‘finger pointing exercises’

‘blame culture’

‘intimidating’

‘denigrating’

‘vindictive’


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.


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.



8:45 am Analysis of case studies, issues arising:

Culture

Systems

Change management

Organisational learning

Network building

Early warning detection



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



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



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



8:45 am Case studies, defi nitions andmodels: Organisationallearning

Senge’s disciplines – systemsthinking, mental models,personal mastery, teamlearning, shared vision



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



8:45 am Case studies, defi nitions andmodels: Early warningdetection

Like the canary down themine, what’s the canary inthe system?



10:30 am Break

Tea and coff ee

See you back here at11:00 am promptly



11:00 am Putting it all together:implementation issues

What do we do now?

I nvolving others



11:00 am [Continued] Putting it all together: implementation issues

What do we do now?

I nvolving others



12:00 Next steps: identif y solutionsand f uture actions

The journey of a thousandmiles …

The next 90 days

Beyond the next 90 days



1:00 pm Wrap up and close

A/ Professor J ohn Rasa



1:15 pm Lunch

Thank you f or yourattendance

Bon voyage

See you at a learning set … .

achse.au/frameset.html achse victoria branch

Documents

healthresidential conference

pastresidential conference

eveningresidential conference

closure day

amcase study

challenger case

relative merits

environmental audit