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

• 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?

• 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

• 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?

• 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?

• 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".

• 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

• 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
  
  
  
  

• 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

• 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.