Process Maps and Root Cause Analysis Seminar 2 Objectives Review QI techniques: root cause analysis, process mapping. Apply techniques to Pat Smith scenario. Apply techniques to selected project. Root Cause Analysis (RCA)
1 Systematic approach to understanding the causes of an adverse event and identifying system flaws that can be corrected Retrospective Not appropriate in cases of negligence or willful harm Important to group contributing factors into categories Focus on system causes, not blame
The Steps of Root Cause Analysis 1 Process mapping Process Mapping2 Useful tool for identifying what happened and what should have happened. Define the boundaries of the process: The
process begins with X and ends with Y. List all the (major or minor) steps that occur in between. Captures the reality of a process for patients. Ideal Process map What should happen 2 Real Process for Patients
What actually happened 2 Ask Why Five Times Why? Problem Why? because...
Why? because Why? because 1 Why?
because because Pat Smith You get a call from Pat Smith, who is angry and scared about the rash she develops. She said that she just got off the phone with the pharmacist who gave her the Augmentin, and
apparently it is a penicillin. She wants to know why you gave her penicillin when she is allergic to it! Other than the rash, she currently feels well and has stopped taking the antibiotic. Lets complete a process map on this error. HOW did Pat Smith receive a penicillin antibiotic when she has a known penicillin allergy?
RCA Categories 1
Patient Characteristics Task Factors Individual Staff Work Environment Organizational & Management Factors Institutional Context Team Factors Fishbone Diagram 1
RCA Challenges3 Appropriate team and meetings All data available, and accurate Team not always using appropriate RCA tools
Everyone not given equal voice at meetings Blame and fear of being blamed, anxiety, guilt still present and not effectively addressed Final report does not always reflect all the issues that came up RCAs for M&M conferences4 Learning objectives of new Patient Safety Morbidity & Mortality Conference at University of MissouriColumbia Distinguish between culture of blame vs culture of safety.
Participate in a modified RCA in order to identify gaps in quality contributing to adverse outcome. Identify strategies to close the gaps. Recommend a plan of action. Recommended interventions were turned into working QI projects with faculty lead about 36% of the time
RCAs for M&M conferences 5 Revised Patient Safety Morbidity and Mortality Conference multidisciplinary with MD, RNs, pharmacists, managers, therapists, admin all present. Cases selected from database of recently reported errors. Panel selected to speak during presentation. Go through modified RCA to identify possible interventions, which they turn over to QI dept for
further work Improved participants perception of culture of safety What About Pat? Now lets continue the RCA for Pat Smiths antibiotic allergy mishap. Create a fishbone diagram. Identify the different factors that played a role in this error. Create causal statements and recommend potential interventions.
Who should be at the table to discuss this error? And Your Project? Now create a root cause analysis for your project, including a process map, fishbone diagram and causes with recommendations for your selected error. References Huber, S. Ogrinc, G. PS 104: Root Cause and Systems Analysis. [IHI Open School online course]. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2010.
http://app.ihi.org/lms/onlinelearning.aspx. July 28, 2010. Accessed March 2016. 2. Quality and Service Improvement Tools: A Conventional Process of Process Mapping. Institute for Innovation and Improvement. 2008. Online http://www.institute.nhs.uk/quality_and_service_improvement_tools/ quality_and_service_improvement_tools/process_mapping_-_a_conventional_model.html. Accessed March 16, 2016. Creative Commons License associated: 1. http://creativecommons.org/licenses/by-nc-nd/3.0/ Nicolini, et al. The Challenge of Undertaking RCA in Health Care: a qualitative study. Journal of
Health Services Research and Policy. Vol 16 Suppl 1, 2011: 34-41. 4. Bechtold, et al. Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasized patient safety. Quality and Safety in Health Care. 2007; 16: 422-427. 5. Szekendi, et al. Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety. The Joint Commission Journal on Quality and Patient Safety. January 2010. Volume 36 Number 1. 3.
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