Download Effective Investigations: Fertilizer for a Safe and Just Culture

Leading Age – St. Louis
August 31, 2015
Why Investigate?
• Address system
issues
• Address people
issues
• Who is your
audience?
A structured process to identify causal or contributing factors
underlying adverse events or other critical incidents to assist in
identifying areas of focus for improvement to prevent the event
from reoccurring.
A step by step questioning process to identify the basic or causal
factors of an error or “near miss” – or any unsatisfactory
outcome or potential outcome.
The end product: a plan of action that will eliminate or mitigate
the risk of an event reoccurring
• Fundamental reason(s) for the
failure or inefficiency of one or
more processes.
• Point(s) in the process where an
intervention could reasonably be
implemented to change
performance and prevent an
undesirable outcome.
• The majority of events have
multiple root causes.
• Prioritize: what can you expect to
improve?
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Active error
Adverse event
Forcing function
Human factors
Incident reporting
Near miss
Sentinel event
Swiss cheese mode
Triggers vs. trigger
questions
• Cause: A cause is an “agency”, perhaps
acting through a long time, or a longstanding situation, that produces an
effect (Dictionary.com)
• Latent cause: An “agency” that has
been around that adds to the risk, but
hasn’t produced an effect—perhaps
until now
• Common cause: An “agency” that is
involved in more than one situation,
not necessarily through the same
pathway, often identified with statistics
• Root cause: digging below the surface.
Investigation and Culture
What makes up culture?
– Values
– Attitudes
– Beliefs
How is culture manifested?
– Practices
– Procedures
– Policies
– Routines of staff and leadership
– Behaviors expected; behaviors that get rewarded
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Definition of Culture
The set of shared attitudes, values, goals and practices that
characterizes an institution, organization or group
-- Merriam Webster
“The way we do things around here”
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Culture-Based Investigation
(With shout-out to Just Culture)
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What happened
What normally happens?
What does policy say should have happened?
What are the reasons for any gaps?
What are we doing to manage this?
Have we selected a good solution?
• What is your policy & process for investigating adverse events
and near misses? Do you have one? Does it work?
• Determine the FACTS & timeline of the event in question.
• What are risks and benefits of one-on-one interviews vs.
group de-briefing. One-on-one is usually better.
• Make sure everyone knows the purpose and that it’s a safe
place to share.
• Who needs to be present to support staff?
• Does the resident or family have relevant information?
• This may take a couple of rounds
• Start with introductions: members of the group & the process
• One or two interviewers; two makes it easier to get good
notes
• Use open-ended questions
• Prepare attendees prior to the debriefing: purpose and
ground rules
• Keep focused on the deliverable outcome of the debriefing:
Facts.
• Don’t commingle this stage with system analysis and action
planning. Use parking lots.
• This includes “what normally happens?”
• Top Leadership’s Role:
– Commitment of resources
– Empowering team to transform processes
• Team member selection:
– Include staff at all levels closest to the issues involved in
the situation
– Individuals critical to implementation of change
– A leader with broad knowledge base
– Individuals with diverse knowledge
• Refer to QAPI structure, fit this in
• Review the purpose of investigation… to change the system
to minimize risk to those in our care
• Everyone is a professional, all are equal
• No sacred cows
• Treat each other with respect
• Validate concerns, but stay on task
• Be open-minded; speak candidly and honestly
• Confidentiality - What is said in the room, about who said or
did what, stays in the room.
• Individual behaviors and decisions are dealt with elsewhere
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Learning From Defects
Five Why’s
Fishbone
Category Table
THESE ARE JUST TOOLS
TO HELP YOU THINK
• IF IT’S DONE RIGHT, THE
ANSWERS ARE THE
SAME
• Describe relevant process in detail- process map
usually helps (see example)
• Ask questions
• Strong listening process for answers
• Amplification where necessary – empower
• Group into categories of causal factors (see fishbone):
– Human factors – communication, fatigue, staffing
– Environment/Equipment
– Rules/Policies/Procedures
– Information management
– Culture
• Include “Parking Lot” for incidental findings
http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2Q2013.pdf
Human Factors
From Dictionary.com:
an applied science that coordinates the design of
devices, systems, and physical working conditions
with the capacities and requirements of the worker
Our Values
• Overlapping Duties?
Yes
• Competing Duties?
You want to land
here
Access to
Care
Privacy
Yes
• We Must Prioritize and
Balance in Support of Our
Values
Safety
Fiscal
Responsibility
Compassion/
Resident rights
• Prioritize
• For each cause, identify:
• corrective measures
• improvement opportunities
• SMART
• Create a timeline
• Assign accountability for
implementation
• Designate a team to
oversee follow-up
• Develop reporting schedule
• Use an engineering approach to failure prevention
• Start with the premise that anything that could go wrong
will go wrong
• Design systems that make it difficult for individuals to err
• Build in as much redundancy as possible
• Use fail-safe design whenever possible
• Simplify processes
• Consider ad-hoc team members - Resources
Controlling Contributing Factors
• Trying to change the pre-cursors to human
error and at-risk behavior
Adding Barriers
• Trying to prevent individual errors
Adding Recovery
• Trying to catch errors downstream
Adding Redundancy
• Trying to add parallel elements
For each example below, describe the one or two principal design
strategies used to manage the risk, then and now.
1. Needle Stick
• 20 years ago:
• Today:
2 IV Medication administration
• 20 years ago:
• Today:
3 Resident getting out of bed
without assistance
• 20 years ago:
• Today:
4 Personal protection from
disease or injury
• 20 years ago:
• Today:
5 Back injury during lifting
• 20 years ago:
• Today:
6 Safe and Effective CPR
• 20 years ago:
• Today:
Problems/
Opportunities
Communication
between shifts
Improvement
Strategy
Scripted handoff
with required input
from various staff
Responsible
Individual(s)
CNA 1 CNA 2
RN
Implementation
Timeline/ Deadline
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
June 15 team
meet
July 1 tool
developed and
policy drafted.
Begin trial with
Cedar Ridge unit
July 15 initial
measurement
Revise as
necessary;
retest
Reporting to/
dates
Measurement Strategy
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Observation
Compliance with
care plans
Reduction in
____ events
Feedback from
staff
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PIP team:
8/1, 9/1
QAPI
oversight
team 9/15
The Guts of the Process
System Processes
 Training
 Accountability
 Equipment and design
 Procedure development
 Choosing the right people
 Dealing with human error policies
Values and Relationships
 Priorities and how they are
communicated
 Response to incidents
 Coaching and teamwork
 What is rewarded or
sanctioned?
 What drives promotions
and terminations?
Exercise
• Volunteers for role play
• Perform interviews – groups based on attendance
– Group interview or individual?
• Design action plan
• Design follow-up measurements
• Select a high-risk process and assemble a team
• Diagram the process (really…draw pictures)
– Observation/mapping
– Interviews
• Conduct a hazard analysis: what could go wrong and why?
• Consider severity and probability of hazards; prioritize.
• Remember to include people who have their hands in the
process
• Action plans
• Parking lot
VA National Center for Patient Safety: The Basics of Healthcare Failure Mode and Effect
Analysis
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Root Cause Analysis
FMEA
Parking Lot
Personnel Management
Send to attorney or insurance co.
Always get back to the person who brought up the issue in the
first place.
• Investigation coaching
assistance for participants
• Aggregate information about
events: numbers, root causes
and action plans
• Work together with other PSO
participants on common
problems—compare
experiences
• Special projects, e.g. falls with
injury/ likely injury and highrisk medication events
• Confidential space for all this
work
• Safety watches and alerts
Contact:
Kathryn Wire
Center for Patient Safety
[email protected]
(314) 540-4910
www.centerforpatientsafety.org
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