A School of Continuous Improvement paper audits four years of Improvement Grand Rounds and finds presenting a case does not reduce its recurrence, only the presenter's odds of an early recall.
A four-year audit of the School of Continuous Improvement's case-review seminar finds presenting a failure does not reduce its recurrence, only lengthens the wait before the presenter is asked back
Presenting a failure at Improvement Grand Rounds does not appear to make it happen again any less often. What the seminar reliably changes is how soon the presenter’s own team is asked back to the podium.
Dr Bram Ntuli, who convenes the seminar, and Dr Osei Vandermeer, Convenor of the Review Cadence Observatory, paired four years of the School of Continuous Improvement’s incident register against the Observatory’s own rostering log. Of sixty-one logged failures eligible for the podium, thirty-four were selected; recurrence ran no lower among the cases that were presented than among the cases the rotation never reached. What moved instead was the interval before the presenting unit’s next invitation, which lengthened with each prior appearance regardless of how full the unit’s incident log stayed.
The University places the audit within its wider commitment to instrumenting its own rituals as rigorously as it instruments everyone else’s, on the view that a seminar built to catch a failure is not exempt from being checked for one.
Convening this seminar for as long as I have, you develop a private theory about what it is actually doing. This is the first time I have checked mine against the roster instead of against my own impression of the room.
— Dr Ntuli
“A scheduling gap is a strange thing to be the most reliable finding in a paper about failure,” said Dr Vandermeer. “We are not yet in a position to say why the roster behaves this way, and we think that is the more interesting question to leave open.”
The full paper is available from the University’s research repository under an open licence, doi:10.5555/slop.qpc8x3.