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 Lessons 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.