Root Cause Analysis and Improvement in the Healthcare Sector

Marti Beltz, Bjørn Andersen

Description

Healthcare organizations and professionals have long needed a straightforward workbook to facilitate the process of root cause analysis (RCA). While other industries employ the RCA tools liberally and train facilitators thoroughly, healthcare has lagged in establishing and resourcing a quality culture. Presently, a growing number of third-party stakeholders are holding access to accreditation and reimbursement pending demonstration of a full response to events outside of expected practice. An increasing number of exceptions to healthcare practice have precipitated a strong response advocating the use of proven quality tools in the industry. In addition, the industry has now expanded its scope beyond the hospital walls to many ancillary healthcare facilities with little experience in implementing quality tools. This book responds to the demand for a RCA workbook written specifically for healthcare, yet still broad in its definition of the industry.
This book contains everything that the typical RCA leader in healthcare requires:
A text specific to healthcare, but using the broadest definition of the industry to include not only acute care hospitals, but rehabilitation facilities, long-term care facilities, outpatient surgery centers, ambulatory services, and general office practices.
A workbook-style format that walks through the process, step-by-step.
Straightforward text without “sidebars,” “tables,” and “tips.” Worksheets are provided at the end of the book to reduce reader distraction within the text.
A wide range of real-world examples.
Format for use by the most naive of users and most basic of processes, as well as a separate section for more advanced users or more complex issues.
Templates, both print and electronic, included for the reader’s use.
Ready-to-use educational materials with scripting to enable the user to train others and garner support for the use of the techniques.
Background text for users in leadership to understand the tools in the larger context of healthcare improvement.
Up-to-date information on the latest in the use of RCA in satisfying mandatory reporting requirements and slaying the myth that the process is onerous and fraught with barriers.
Background text and tools/process are separated to facilitate the readers’ specific needs. Healthcare leaders can appreciate the current context and requirements without wading through the actual techniques; end-users can begin learning the skills without wading through dense administrative text.
Language and tone promoting the use of the tools for improvement of processes that have experienced exceptions, as opposed to assigning blame for errors.
Attention to process ownership, training, and resourcing.
And, most importantly, thorough description of the improvement process as well as the analysis.

Sujets

• Risk Assessment
• Gestion et management
• Insurance
• Economics
• Business
• Management

Informations

• Publié par: ASQ Quality Press
• Date de parution: 09 novembre 2009
• Nombre de lectures: 0
• EAN13: 9780873891257
• Langue: English
• Poids de l'ouvrage: 5 Mo

Extrait

Root Cause Analysis and Improvement in the Healthcare Sector

Also available from ASQ Quality Press:

Solutions to the Healthcare Quality Crisis: Cases and Examples of Lean Six Sigma in Healthcare Søren Bisgaard, editor

Improving Healthcare with Control Charts: Basic and Advanced SPC Methods and Case Studies Raymond G. Carey

LeanSix Sigma for Healthcare: A Senior Leader Guide to Improving Cost and Throughput, Second Edition Greg Butler, Chip Caldwell, and Nancy Poston

The Public Health Quality Improvement Handbook Grace L. Duffy and John W. Moran, editors

Lean Six Sigma for the Healthcare Practice: A Pocket Guide Roderick A. Munro

A Lean Guide to Transforming Healthcare: How to Implement Lean Principles in Hospitals, Medical Offices, Clinics, and Other Healthcare Organizations Thomas G. Zidel

Improving Healthcare Using Toyota Lean Production Methods: 46 Steps for Improvement, Second Edition Robert Chalice

On Becoming Exceptional: SSM Health Care’s Journey to Baldrige and Beyond Sister Mary Jean Ryan, FSM

Journey to Excellence: Baldrige Health Care Leaders Speak Out Kathleen Goonan and Patricia K. Stoltz, editors

Benchmarking for Hospitals: Achieving BestinClass Performance without Having to Reinvent the Wheel Victor Sower, Jo Ann Duffy, and Gerald Kohers

Business Process Improvement Toolbox,Second Edition Bjørn Andersen

The Quality Toolbox,Second Edition Nancy R. Tague

To request a complimentary catalog of ASQ Quality Press publications, call 8002481946, or visit our Web site at http://www.asq.org/qualitypress.

Root Cause Analysis and Improvement in the Healthcare Sector

A StepbyStep Guide

Bjørn Andersen, Tom Fagerhaug, and Marti Beltz

ASQ Quality Press Milwaukee, Wisconsin

American Society for Quality, Quality Press, Milwaukee 53203 © 2010 by ASQ All rights reserved. Published 2009 Printed in the United States of America 15 14 13 12 11 10 09 5 4 3 2 1

Library of Congress CataloginginPublication Data

Andersen, Bjørn.  Root cause analysis and improvement in the healthcare sector : a stepbystep guide / Bjørn Andersen,  Tom Fagerhaug, and Marti Beltz.  p. ; cm.  Includes bibliographical references and index.  ISBN 9780873897808 (ring bound : alk. paper)  1. Medical errors—Prevention. 2. Medical care—Quality control. I. Fagerhaug, Tom, 1968–  II. Beltz, Marti. III. Title. [DNLM: 1. Quality of Health Care. 2. Health Facilities—organizations  & administration. 3. Systems Analysis. W 84.41 A544r 2010]  R729.8.A53 2010  610.28'9—dc22 2009052472

ISBN: 9780873897808

No part of this book may be reproduced in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher.

Publisher: William A. Tony Acquisitions Editor: Matt T. Meinholz Project Editor: Paul O’Mara Production Administrator: Randall Benson

ASQ Mission: The American Society for Quality advances individual, organizational, and community excellence worldwide through learning, quality improvement, and knowledge exchange.

Attention Bookstores, Wholesalers, Schools, and Corporations: ASQ Quality Press books are available at quantity discounts with bulk purchases for business, educational, or instructional use. For information, please contact ASQ Quality Press at 8002481946, or write to ASQ Quality Press, P.O. Box 3005, Milwaukee, WI 532013005.

To place orders or to request ASQ membership information, call 8002481946. Visit our Web site at www.asq.org or http://www.asq.org/qualitypress.

 Printed on acidfree paper

Table of Contents

CDROM Contents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . List of Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 1 Root Cause Analysis in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . All Organizations Have Problems—Why Is RCA So Important in Healthcare?. . . . . Brief History of RCA in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definition of a Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Different Levels of Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Nature of Variation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Root Cause Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Related Tools, Processes, and Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SystemLevel Impediments to Effective RCAs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PersonLevel Impediments to Effective RCAs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PracticeLevel Impediments to Effective RCAs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 2 The Root Cause Analysis Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Root Cause Analysis Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Explanation of the Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Full Process Case Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chapter 3 Step 1: Define the Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Purpose of Step 1: Define the Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Substeps in Step 1: Define the Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1a: Trigger the RCA Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1b: Mandate and Organize the RCA Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1c: Plan the RCA Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

v

xi xiii xv 1 2 3 5 6 7 8 9 10 11 12 13 14 16 17 20 21 22 23 24 25 26

vi Table of Contents

Gantt Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1d: Describe the Event in Detail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Eliminate Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Checklist for Step 1: Define the Event. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RFO Case Step 1: Define the Event. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Project Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Defining the Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 4 Step 2: Find Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Purpose of Step 2: Find Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Substeps in Step 2: Find Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a: Process Mapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Flowchart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Flowchart Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2b: HighLevel Mapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contextual and Environmental Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2c: Brainstorming of Possible Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fishbone Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example Fishbone Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Checklist for Step 2: Find Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RFO Case Step 2: Find Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HighLevel Mapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Identifying Possible Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 5 Step 3: Find the Root Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Purpose of Step 3: Find the Root Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Substeps in Step 3: Find the Root Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3a: Categorizing Possible Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Possible Cause Category Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3b: Constructing a CauseandEvent Tree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example CauseandEvent Tree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3c: Analyze Possible Causes to Find the Root Cause . . . . . . . . . . . . . . . . . . . . . . . . . Five Whys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example Five Whys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fault Tree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example Fault Tree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Problem Concentration Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example Problem Concentration Diagram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Span of Control Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3d: Collate the Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example Collate the Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27 28 29 30 31 32 33 35 36

37 38 39 40 41 42 43 44 45 46 47 48 49 51 52

53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69

Table of Contentsvii

Checklist for Step 3: Find the Root Cause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RFO Case Step 3: Find the Root Cause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CauseandEvent Tree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Five Whys to Find Root Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Collating the Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chapter 6 Step 4: Find Solution(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Purpose of Step 4: Find Solution(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Substeps in Step 4: Find Solution(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4a: Explore the Root Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exploration of the Root Cause in Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4b: Identify Solution(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Benchmarking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Using Benchmarking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4c: Specify/Describe the Solution(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Checklist for Step 4: Find Solution(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RFO Case Step 4: Find Solution(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Benchmarking for Solutions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Describing the Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 7 Step 5: Take Action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Purpose of Step 5: Take Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Substeps in Step 5: Take Action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a: Analyze the Implementation Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Force Field Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example Force Field Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5b: Decide on the Implementation Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5c: Create an Accepted Implementation Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Implementation Plan/Project Proposal Sample Structure . . . . . . . . . . . . . . . . . . . . . . 5d: Communicate and Create Ownership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5e: Implement the Solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Checklist for Step 5: Take Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RFO Case Step 5: Implementation Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Deciding on the Implementation Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Implementation Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Creating Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 8 Step 6: Measure and Assess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Purpose of Step 6: Measure and Assess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Substeps in Step 6: Measure and Assess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6a: Conduct a Pilot Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6b: Undertake Measurements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Usages of Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87

89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104

105 106 107 108 109 110

viii Table of Contents

Effective and Efficient Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6c: Assess the Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6d: Put in Place Safeguards Against Event Reoccurrence. . . . . . . . . . . . . . . . . . . . . . 6e: Report and Close the RCA Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Checklist for Step 6: Measure and Assess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RFO Case Step 6: Measure and Assess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Modifying the Solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reporting and Closing the Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 9 Advanced Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Advanced and Basic Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spider Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Steps in Using a Spider Chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example Spider Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Critical Incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example of Critical Incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Check Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example Check Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bottleneck Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Steps in Using Bottleneck Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example Bottleneck Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Histogram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Steps in Creating a Histogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example Histogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pareto Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example Pareto Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scatter Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example Scatter Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Performance Matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Steps in Using a Performance Matrix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example Performance Matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Failure Mode and Effects Analysis (FMEA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Steps in FMEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example FMEA Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Six Thinking Hats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Steps in Using Six Thinking Hats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Impact Effort Matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example Impact Effort Matrix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 10 Hardwiring the Use of RCA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prioritizing Responses and Resource Allocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Increasing the Timeliness of Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

111 112 113 114 115 116 117 118

119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151

Table of Contentsix

Increasing the Strength of Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Calculating the Business Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Using Classification Taxonomies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conducting MetaAnalysis of RCAs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Publishing Results and Creating Best Practice Toolkits . . . . . . . . . . . . . . . . . . . . . . . Providing Transparency in Tools and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 11 The Future of Root Cause Analysis in Healthcare . . . . . . . . . . . . . . . . . . What Is Next?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Advanced Research: Understanding of the Nature of Human Error and High Reliability Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Creating a Culture of Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Instituting Policy and Process Specifics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Increase in Transparency and Incentives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Increased Standardization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Collection of Best Practice Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Increase in Resources and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Move to Critique and Increase Accountability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A. Templates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RCA Reporting Framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RCA Team Mandate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RCA Team Composition Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gantt Chart Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fishbone Chart Template. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Five Whys Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Force Field Analysis Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spider Chart Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Check Sheet Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pareto Chart Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scatter Chart Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Performance Matrix Template. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FMEA Worksheet Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Impact Effort Matrix Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Histogram Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Guidelines for Evaluating RCAs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C. Adverse Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D. Suggested Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E. Institutions and Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . F. RCA Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G. Resource CD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

152 153 154 155 156 157 159 160

161 162 163 164 165 166 167 168

169 171 172 174 175 176 177 178 179 180 181 182 183 184 185 186 187 189 195 201 203 209 227