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 Sentinel Event Policy

• Will the CEO support a policy for root cause analysis in response to a sentinel event?
• Will the Medical Staff leadership support these policies and procedures?
• What is your organization’s policy for reporting sentinel events and root cause analysis to the Joint Commission?

Assess: Policies and Procedures

• Patient or customer complaints
• Occurrence or incident reporting
• Medication error reporting
• Claims and incident investigations
• Current analysis processes
• Adverse event or sentinel event policy
• Performance or continuous improvement
• Clinical or practice pathway variances

Assess: Organizational “Climate”

• Do you have a culture which supports continuous improvement?
• Are your health care providers competent in using the tools of process improvement?
• Does your leadership emphasize “patient satisfaction”?
• Does your organization place importance on “patient safety”?
• Do employees and medical staff report incidents/events in a timely manner?
• Do staff “fear” punitive measures against them for reporting adverse events?
• Does information flow freely throughout the organization?

Assess: Organizational Training Requirements

• Are resources for training available?
• Identify what to teach
• Who will provide root cause analysis training for the staff?
• Do you in-house expertise in this area?
• Will you have to “out source”?
• Which staff members will require specialized training?
• How best can training be delivered?

Assess: Information Management Resources

• Do you have internal or Internet access?
• Do you have email capability?
• Do you have an organization-wide Intranet?
• Do you have the capability to electronically pass documents between employees?
• Can this new technology be useful for instruction and “internal marketing”.

Create a Risk Management Committee

• Multi-disciplanary team
• Meet regularly to discuss risk exposure issues
• Holds protected, secure data repository
• Active medical staff membership
• Review of events and assignment of root cause analysis (include “near misses”)
• Review and approval of each completed root cause analysis

Points to Consider: Lessons Learned

• Get Senior Leadership Support Up Front
• Strive toward a culture of patient safety
• Revised written plan, policies and procedures
• RM Program Training
  • All departments and work centers
  • Involved medical staff in training
  • Continuous Improvement Collaborative
  • Specialized performance improvement training for department representatives
  • Root cause analysis training is key
  • Use Intranet/LAN for online training and support
• Close collaboration with
  • Performance Improvement Office
  • Medical Staff Leadership
  • Nursing Leadership
  • Legal Counsel

More Lessons Learned

• Remember to keep your sense of humor
• Cultivate “physician champions”
• Keep medical staff involved in all steps of the process
• Keep the leadership informed
• Teach, teach and teach some more…
• Concentrate on support and assistance for the root cause analysis process
• Ensure a literature search accompanies each root cause analysis if at all appropriate
• Constantly pursue the “credible and thorough” root cause analysis
• Ensure that your organization has a process to monitor and measure recommendations and improvements

More Lessens Learned

• Spotlight your root cause analysis superstars
• Create a award/reward/incentive system for participation
• Be patient – stay for the “long run”
• Ensure each root cause analysis is conducted by an “expert” team
• Ensure feedback to participants.