Premortem Tool

Problem Statement

Projects often fail due to many circumstances. Quality improvement programs, like the Comprehensive Unit-based Safety Program (CUSP) are no exception. Understanding potential barriers and complications to project implementation and success BEFORE the launch of a new program can mitigate and hopefully prevent failure.

What Is a Premortem?

The concept of a project premortem was developed by Gary Klein and published in the Harvard Business Review in September 2007. Klein based the idea of a project premortem on the postmortem of a deceased patient. In a postmortem, an autopsy is conducted to determine a patient’s cause of death, but does not help that particular patient. In a project premortem, prior to the project launch, the project team imagines the project has failed and brainstorms all of the reasons that could lead to this failure. The team then develops plans to mitigate these reasons for failure.

What Is the Purpose of This Tool?

The purpose of the CUSP Premortem Tool is to help the CUSP coordinator and team anticipate and mitigate problems.

Who Should Use This Tool?

The organization-level CUSP coordinator should use this tool to facilitate the discussion with the CUSP champions, the unit manager, and the CUSP team.

When Should This Tool Be Used?

The CUSP Premortem Tool should be used after assembling the CUSP team and when all CUSP team members, including the executive, are trained in CUSP. It is also helpful to discuss the culture survey results before conducting the premortem exercise.

You may wish to conduct the premortem with the CUSP executive and core CUSP team.

How Should This Tool Be Used?

Follow the directions in the order that they are written. Instruct the team to be honest and open to sharing all concerns.

Materials

Bring the materials listed below to the meeting of core CUSP team members. 

• CUSP Premortem Unit Input Sheet (copies for everyone plus some extra).
• Pens, markers, and Sharpie markers.
• Flipchart and easel or a whiteboard.
• Small circle stickers.

Step 1: Explain Premortem Exercise

Explain the idea of a premortem and the instructions.

• Use the description of a premortem on the first page of this tool.
• Encourage everyone to share all concerns.
• Distribute the Premortem Input Worksheet (on page 4, or you may use blank pieces of paper) and pens to each person.
• Say the following:
  • "Imagine that we are 2 years into the future, and despite all of the team’s efforts, CUSP has failed on this unit. Things have gone completely wrong on a number of fronts. What could have caused this?"
  • "Spend the next 10 minutes writing down all the reasons you believe this failure occurred. Please work independently and write down anything that comes to mind."

Step 2: Debrief Responses

• After 10 minutes, go around the room asking everyone to share one reason that has not already been mentioned. Repeat until all reasons are mentioned.
• Note the reasons on a board or easel in the room for all to see.
• Once all reasons are mentioned, briefly read through the reasons listed on the board.

Step 3: Prioritize Ideas

There are several ways to quickly and equitably get input on priorities.  It is very important that everyone on the team have a voice in prioritizing, so the method used should be democratic and not allow the most vocal people to select the priorities.

A common method is voting nonverbally, using this approach:

• Tell each team member that they have 2 minutes and four votes, and ask each of them, working independently, to select their top four concerns.
• Once they have completed this, identify the concerns with the most votes and list them on a separate piece of paper/board. 
• Options for voting:
  • Provide four stickers to mark the top ideas.
  • Mark four top ideas with pens/markers.

Step 4: Brainstorm Interventions

For each of the three or four top-priority concerns, brainstorm interventions that could be done during CUSP implementation to mitigate the concern. Again, it is very important that everyone on the team have a voice in prioritizing, so the method used should be democratic and not allow the most vocal person or a vocal minority to have unbalanced input. Good facilitation will allow a solid group discussion and generate ideas.

Another common method to ensure everyone feels their voice is heard is the affinity exercise, a nonverbal idea generation methodology.

• Provide "sticky notes."
• List each concern on a white board or flip chart.
• Instruct team to write one idea per note for interventions to mitigate each of the concerns.
• Work for 10 minutes independently with a goal of high volume.
• Place the notes on the white board or flip chart under the concern.
• After 10 minutes, read (or ask another team member to read) the ideas and place the ideas in categories.
• Facilitate a discussion to prioritize the ideas.
• Consolidate a list of the selected ideas or interventions.
• Assign each intervention to a team member.

Step 5: Follow Up

Explain that the CUSP team will be responsible for working on these interventions and that the team should review the Premortem Results List at CUSP meetings.

In addition, the CUSP team should periodically review the entire concern list to determine if any other concerns should be addressed.

Premortem Input Worksheet

We are using a CUSP Premortem prior to launching CUSP on this unit, in order to brainstorm and then address potential barriers to or complications of implementing CUSP. This tool helps us imagine the project has failed and brainstorm all of the reasons that could lead to this failure. The team will then develop plans to mitigate these reasons for failure.

Today: Imagine that we are 2 years into the future, and despite all of the team’s efforts, CUSP has failed on this unit. Things have gone completely wrong on a number of fronts. What could have caused this? Please spend the next 10 minutes writing down all the reasons you believe this failure occurred. Please work independently and write down anything that comes to mind.

CUSP Premortem Results