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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? o o o o o o o o o 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 9 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” 10 Culture-Based Investigation (With shout-out to Just Culture) • • • • • • 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 • • • • • 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 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 Observation Compliance with care plans Reduction in ____ events Feedback from staff 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 • • • • • 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 36