Root Cause Analysis and Sentinel Event Policy Implementation: Lessons Learned

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.

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