- 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?
- 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.