leading age – st. louis august 31, 2015. why investigate? address system issues address people...
TRANSCRIPT
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Effective Investigations
Leading Age – St. LouisAugust 31, 2015
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Why Investigate?
• Address system issues
• Address people issues
• Who is your audience?
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What Will You Be Learning Today?
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
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Don’t Over-Complicate Things
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What You’re Looking For
• 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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Looking for the magic bullet?
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Investigation: Key Definitions
o Active erroro Adverse evento Forcing functiono Human factorso Incident reportingo Near misso Sentinel evento Swiss cheese mode
o Triggers vs. trigger questions
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The Vocabulary
• Cause: A cause is an “agency”, perhaps acting through a long time, or a long-standing 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.
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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)
• 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?
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Where to Begin? Learn What Happened.
• 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
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De-briefing: Just the Facts
• 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?”
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System Investigation Process: Organize a Team
• 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
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Ground Rules for the Team
• 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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Tools
• 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
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Determine the “Root Cause”
• 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
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Root Causes of Sentinel Event Reported to TJC
http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2Q2013.pdf
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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
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Our Values
• Overlapping Duties?Yes
• Competing Duties?Yes
• We Must Prioritize and Balance in Support of Our Values
Access to Care
Compassion/ Resident rights
Fiscal ResponsibilityPrivacy
Safety
You want to land here
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Develop Risk Reduction/Action Plan
• 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
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Explore Solutions
• 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
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Designing Effective Systems
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
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Exercise
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:
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Action Plan
Problems/ Opportunities
Improvement Strategy
Responsible Individual(s)
Implementation Timeline/ Deadline Measurement Strategy Reporting to/
dates
Communication between shifts
Scripted handoff with required input from various staff
CNA 1 CNA 2 RN
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
Observation Compliance with
care plans Reduction in
____ events Feedback from
staff
PIP team: 8/1, 9/1
QAPI oversight team 9/15
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CPS’ Root Cause Analysis Tool
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CPS’ Root Cause Analysis Tool
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The Guts of the Process
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Don’t Forget the Background and “Soft” Stuff
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?
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Exercise
• Volunteers for role play• Perform interviews – groups based on attendance
– Group interview or individual?• Design action plan• Design follow-up measurements
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FMEA: Investigating the Event that Hasn’t Happened
• 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
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Process Flow
VA National Center for Patient Safety: The Basics of Healthcare Failure Mode and Effect Analysis
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Which is Best?
• Root Cause Analysis• FMEA• Parking Lot• Personnel Management• Send to attorney or insurance co.
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Closing the Loop
Always get back to the person who brought up the issue in the first place.
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The Role of the Patient Safety Organization
• 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 high-risk medication events
• Confidential space for all this work
• Safety watches and alerts
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Questions?
Contact:
Kathryn WireCenter for Patient Safety
[email protected](314) 540-4910
www.centerforpatientsafety.org