Failing by Design:
why winter is a season, not a surprise
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
Execute
Impact
Plan
Design
Execute
Impact
Plan
Design
Execute
Impact
Plan
Review
Impact
Design
Execute
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’
Unacceptable
outcomes
Unacceptable
Workload
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)
• 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
Production planning
July
August
September
2011 budgeted
109
109
109
2011 actual
117
135
187
2012 budgeted
102
102
102
2012 actual
117
155
148
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’)
Critical Zone
Degraded Zone
Stretch Zone
Ideal Operating Zone
Sub-productive
Unproductive
Lawless 2013
Critical Zone
Degraded Zone
Stretch Zone
Ideal Operating Zone
Sub-productive
Unproductive
Lawless 2013
Critical Zone
Degraded Zone
Stretch Zone
Ideal Operating Zone
Sub-productive
Unproductive
Lawless 2013
Critical Zone
Degraded Zone
Stretch Zone
Ideal Operating Zone
Sub-productive
Unproductive
Lawless 2013
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
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
Death Zone
INCREASED LOS
CANCELLATIONS
TREATMENT DELAYS
Critical Zone AVOIDABLE DEATH
AVOIDABLE HARM
Degraded Zone
STAFF OVERTIME
Stretch Zone
Ideal Operating Zone
Sub-productive
Unproductive
WASTED CAPACITY – UNABLE TO BE REINVESTED
Lawless 2013
Care Capacity Demand Management:
strengthening resilience
Smoothing
Variance
Base staffing
design
Responding to
variance
Base & buffer
Recovery planning
Addressing the
blind spot
Critical metrics
Smoothing variance & improving
staffing design
Variance Response Management:
Capacity at a Glance
Event Report
Daily report
Click on
event
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
Care Capacity
Demand
Management
 PRODUCTIVITY/FLOW/VOLUME TARGETS ACHIEVED
 ADHERENCE TO BUDGET
PLANNING AND RESOURCING THE FUTURE
REFINE DESIGN OVER TIME
CCDM Council
Monitors persistent
issues with Indicator Set
Recommends design
changes to organisation
Service/Ward
Core Data
Set
Ward Data Council
•Adapts local design
and responses
•Recommends
change to operational
design and responses
Mix & Match
Set base staffing design
Set base resource design
Central Operations
Management
•Reallocating resources
•Adjusting care capacity
& demand using
Standard Operating
Responses
Service/ Ward
Management
•Uses Standard
Operating Responses
CARE CAPACITY DEMAND MANAGEMENT
EVERYDAY VARIANCE MANAGEMENT
Organisational planning, design & resourcing
•Forecast demand
•Resource matching
•Budgeting
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
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 are we able to do?
RE SET DEMAND FORECAST
NO
Address the gap
What capacity will it take to
deliver that?
(CAPACITY MATCH)
-BASE STAFFING
MODELLING
-(PLANT)
-(SUPPLIES)
-(SUPPORT
INFRASTRUCTURE)
Do we have the finances &
resource capacity to support
that?
YES
ESTABLISH RESOURCES
-CAPACITY/DEMAND
FORECASTING
-WORKPLACE DESIGN
DEVELOP & IMPLEMENT PRODUCTION PLAN
BASED ON CAPACITY/DEMAND
PROJECTIONS
MONITOR FOR MID RANGE VARIANCE &
ACTIVELY REDESIGN
(up to 6 weeks out)
COLLECT IMPACT
METRICS
DELIVER SERVICES
-DEMAND FLOW
DEAL WITH EMERGENT
VARIANCE
-Variance smoothing
-↑↓ Demand
-↑↓Capacity
-Redistribute demand or
capacity
-Make sacrificing decisions