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FMEA – half day workshop

FAILURE MODES &


EFFECTS ANALYSIS

Facilitator: Liz Cox (Risk Management Advisor VMIA)

VICTORIAN MANAGED INSURANCE AUTHORITY


FMEA - half day workshop

Welcome
ƒ Housekeeping

Agenda
ƒ Program overview
ƒ Learning objectives
ƒ Feedback and recommendations from 22nd October
ƒ Presentations
ƒ Revised materials
ƒ Statewide strategy

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Objectives of today

ƒ Consolidate the application of FMEA methodology


ƒ Consolidate the learnings from project and change
methodology
ƒ Share lessons learned
ƒ Understand further the best fit and use for FMEA in a
health service
ƒ Agree on a strategic approach to FMEA in healthcare

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Feedback and evaluation

Summary feedback
ƒ Workshop feedback 22nd October
ƒ Evaluation forms 22nd October
ƒ Queries and discussion from participants between
workshops

ƒ Gov Dex – hits


ƒ 50 as at 21st October
ƒ 76 as at 24th Feb

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Evaluation
FM EA Fe e dback Re sults

3
Average

0
The Program Environm ent Facilitator Program Res ults
Average 4.45 4.6 4.65 4.35

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Feedback from 22nd October

ƒ “Sharing problems was great, ready to go back and start again”


ƒ “A lot more helpful to see how other organisations going with
FMEA tool”
ƒ “Found that today’s session was far more valuable”
ƒ “I found today far more interesting and beneficial especially
viewing other examples”
ƒ “A useful session”
ƒ “This was a useful day on a topic I have had some problems
with”
ƒ “Hearing how the other services are going with their
implementation hearing what has worked well and not so well”

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Team Case Study Presentations
Royal Children’s Hospital
ƒ The documenting of patient alerts on admission to hospital and how this is communicated
to relevant staff

Bayside Health
ƒ Follow up of Patients who have abnormal x-ray results which were not communicated to
the patient prior to discharge from the Emergency Department

Austin Health
ƒ Review and Management of Serious Falls (ISR 1’s and 2’s)

Southern Health
ƒ Review failure modes surrounding the communication of clinically urgent results for
inpatients and Emergency patients.

VMIA
ƒ Learning and development (training) planning and development

Melbourne Health
ƒ Ensuring Correct Patient and Procedure in Radiology

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Revised Tool
Process Step

Detectability
C(Sev)
VA

NVA

RPN
L (Occ)
Failure Modes

Current Controls
Effects

Treatments
Causes

Response

Closed out

Cons2

L2

Det2

RPN2
Next:
1. Analyse the cost of labour
2. Graph consequence verses effort (risk of not doing the change)
3. Provide a report

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Where to from here ?

STRATEGY- key points


ƒ Statewide approach
ƒ Advisory group DHS/VQC
ƒ Delivery - VMIA external training program
ƒ Case studies and lessons learnt
ƒ Software development of tool (pending approval)
Evaluation report

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