Reprinted with permission from: The Joint Commission Advisor for Behavioral Health Care Providers, June 1999, 3(6), pp 1-4. While this article focuses on behavioral health, the comments are fully applicable to health care in general.   It’s a thorny issue, and one that lawmakers are not likely to resolve anytime soon: How can behavioral health care[…]

First Considerations Assessment of your organization’s “reality” Ask the hard questions Discover feasibility “up-front” Write or revise your plan of action Add or revise policies and procedures (include flow charts) Responsibility and accountability – who does what? Training Methods for monitoring & feedback Implement, monitor and make necessary adjustments Assess: Top Leadership Acceptance of the[…]

Software Facilitation   CCD Health Systems owns and promotes its methodology for conducting cost-effective root cause analysis in the healthcare environment. This methodology also provides an effective and standardized process for performing peer reviews and morbidity/mortality reviews.   Root Cause Analyst® is the software product based upon that methodology. It is designed to lead an[…]

PEER REVIEW STATUTES: PROTECTING YOUR INTERESTS Reprinted with permission from: The Joint Commission Advisor for Behavioral Health Care Providers, June 1999, 3(6), pp 1-4. While this article focuses on behavioral health, the comments are fully applicable to health care in general.   . . if the organization has concerns about increased risk of legal exposure as[…]

With the burgeoning interest in healthcare failure mode and effects analysis (HFMEA®), there have unfortunately been systematic errors injected into the methodology, even in the examples promulgated by the leaders in the patient safety movement. The errors are in design and application of the HFMEA methodology, as it was transitioned from its non-healthcare origins to[…]

Prelude: If you have a sentinel event, and if you don’t have a formal process already in place, you’ve essentially lost this battle already, because you’re in the position of crisis functioning. Recoup by bearing in mind that the JCAHO is expecting a gradual development of processes for conducting Root Cause Analyses™, and is likely[…]

Using multi-disciplinary teams to conduct Root Cause Analysis leads to innovative solutions while simultaneously transforming group dynamics By: Denise G. Osborn, JD, MPH(2008)   What is Root Cause Analysis? Root Cause Analysis (RCA) is an effective tool that can be used to study why something that is undesirable has happened. A multi-disciplinary team works collaboratively[…]

The move to conduct root cause analysis is largely motivated by a growing recognition that the complexity of health care and health care delivery drives the incidence of adverse events uncomfortably and unacceptably high (Brennan et al, 1991). Consistent with this, the National Patient Safety Foundation (NPSF) maintains as its philosophy that:   Most errors[…]

The Joint Commission requires that your Root Cause Analysis (RCAs) be thorough and credible. “Thorough” and “credible” are not particularly difficult concepts until it’s time to apply them while conducting an RCA. Or when the The Joint Commission comes calling during survey to make sure your systems are up to snuff, including your RCAs. However,[…]