This week’s blog is on Risk Treatment. It is an important step in completing the Plan-Do-Check-Act cycle for continuous quality improvement. Much like a doctor and her patient, before we can treat our operations, we need to diagnose what the problem is and where our treatment should be applied. Once the cure has been diagnosed, the doctor can set out a plan of action for effective treatment to nurses, supportive staff and keep administrative tabs. Once those actors come into play, the treatment needs to be evaluated regularly to see if it is, in fact, curing the patient. After effective treatment, the patient may be discharged, and operations should resume more safely again.
If the 8 steps of the bowtie were carried out successfully, any glaring gaps should become immediately visible. Search, for example, for any threats without barriers on them. Finding these ‘open wounds’ will improve your risk-based decision making by helping you allocate your often limited resources more effectively.
After completing the 8 steps, using the metadata defined in previous blogs will further assist you in finding soft spots in your system. For example, are there any barrier lines that all have the same barrier type? If the answer is yes, the diagnosis is simple: vary the type of barriers.
Once the diagnosis is clear, the accountable people must be assigned. Who is in charge of ensuring that extra barriers are added? Who is responsible for introducing different types of barriers? Who is accountable for updating the procedures? Having defined the action party, a deadline must be given. Before what date should the treatment have been completed? What is the priority of said treatment? Is it of the highest importance? Or can it wait in favor of more urgent other treatments? This will help your decision makers to prioritize and thus more effectively allocate resources.
Assessing whether the proposed treatment is actually effective is an often-overlooked vital part of the PDCA cycle. Someone needs to review whether the treatment has A) been completed, and B) been effective. Does the new change, in fact, make the system safer?
When all these steps have been completed, we are back at the planning phase and the cycle starts anew. The paper world should now more closely reflect the real world, for at least a short while, until the real world changes again, as it always does.
To find out how to try to keep up with the ever-changing world around us, read next week’s blog on Action Tracking in the BowTieServer.