News: PQI News

Engage Stakeholders & Learn How a Program Will Fail: A Brainwriting Postmortem

Tuesday, March 6, 2018  
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Guest Post by: Heather Gilmartin, PhD, NP; Investigator, Nurse Scientist; Denver/Seattle Center of Innovation; Department of Veterans Affairs

Do you have a brilliant, evidence-based program that you want to implement at your unit or hospital?

Have you received approval from leadership, but need to engage those who will be doing the work?

Do you work in an environment where staff might not feel open to sharing ideas in a group setting?

If you answered yes to any of these questions, then you should think about hosting a brainwriting premortem session as part of your pre-implementation plans.

The brainwriting premortem method was created for a five-year, mixed-methods national quality improvement project. We needed to engage stakeholders to find out how our evidence-based program would fit within the context of their individual organizations. We knew we would not have much time to build rapport with teams since we were only on-site at each organization for 2 days. We also knew that healthcare providers work in environments with significant professional, social, and status differences. This can make some team members not feel safe to voice their ideas without fear of embarrassment, getting into trouble or being punished (i.e., psychological safety).

We needed a method that could quickly engage stakeholders, create an environment of psychological safety, and gather feedback from each individual to maximize the effectiveness of implementing of our planned QI project. What I found were two methods commonly used for brainstorming and evaluation: the brainwriting method and the project premortem.

Brainwriting is when a group of people get together and write out ideas on a specific topic. The process involves one person writing ideas on a sheet of paper, then passing the paper to other members of the group. Participants are given time to read, reflect and expand on each other’s ideas. The goal of passing papers from one person to the next is to share ideas, trigger new ideas, and prompt innovative and out-of-the box thinking.

A premortem is the hypothetical opposite of a postmortem. In healthcare, a postmortem allows the healthcare team to learn what caused a patient’s death. Everyone benefits, except the patient. The same idea can be translated to project implementation. A premortem in a project planning setting comes at the beginning of a project rather than the end, so that the project can be improved rather than autopsied. Unlike a typical problem identification session in which stakeholders are asked what might go wrong, the premortem assumes that the project has been implemented and failed, and asks what did go wrong. The stakeholder's task is to generate plausible reasons for the project's failure.

I combined the two methods to create the “Brainwriting Premortem” and set out to test it at 10 Veterans Health Administration hospitals and primary care clinics. During each site visit, we spent time observing staff and interviewing key stakeholders. We ended each two-day visit with a 60 to 90-minute group activity that included sharing information regarding our program, a process mapping activity, and then a 10-minute brainwriting premortem session. Though getting key stakeholders into a conference room together was not easy, once they arrived they were highly engaged and ready to share their knowledge.

We placed a pile of papers in the middle of the table and made sure everyone had a pen or pencil. The leader started the exercise by informing everyone that the (proposed) program has failed spectacularly. For 10 minutes, those in the room wrote down every reason they could think of for the failure – especially the kind of things they ordinarily might not mention as potential problems, such as system issues or political hotspots.

Participants reviewed others’ written ideas for inspiration or to expand further on a proposed idea by writing on the same piece of paper. If a participant couldn't come up with an idea in a reasonable time period, they returned the paper without writing anything. Once 10 minutes were up, the leader collected the pages and let participants debrief amongst themselves.  

We were amazed by the results. Across the ten sites we engaged 116 clinicians and administrators (range: 2 to 26; average: 11.6). Participants produced 217 potential barriers to program implementation that fell into ten common themes. The data were hand written and immediately available. After some sessions, participants started brainstorming potential solutions and adaptations we could make to help the program be successful at their site. We took note of the barriers and potential solutions and made changes to our program and educational plans. Because the data was immediately available, we were able to create leadership feedback reports in a short amount of time.

Participants looked like they were having fun. The writing appeared to help participants think and provided ideas for other people to comment and expand on. One facilitator noted that participants appeared flattered that they were being asked their opinions, "…almost as if no one had ever asked their opinions before." Another facilitator witnessed "light bulbs going off" when something was read by a participant that they hadn't thought of before. When we surveyed participants after sessions, they indicated they were not afraid to give ideas to the group and were not worried that they would be criticized. The brainwriting premortem method had created an environment of psychological safety.

When should you use the brainwriting premortem method?


… you want to rapidly gather ideas about a new program from those who will be doing the work.

… you have limited amount of time and resources

… you have limited (or no) experience in group facilitation

… you want to engage stakeholders early in a project

… you want to be upfront that your program will not be perfect from the start

… you want help from those doing the work to adapt and reinvent aspects of your program to move it forward 

… you want to create an environment where everyone feels able to share their ideas

For more details on using this method with your team or group, please refer to the brainwriting premortem guide.


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