Patient Safety: The PROACT Root Cause Analysis Approach

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ISBN: 9781420087277 | 1420087274
Cover: Hardcover
Copyright: 10/14/2008

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Written by a reliability expert, this book provides a perspective on patient care from outside the healthcare industry and culture. Challenging perceptions about Root Cause Analysis (RCA), it provides a new approach that includes tools such as Basic Failure Modes and Effects Analysis (FMEA) and Opportunity Analysis (OA) which help quantify and prioritize events which deserve the attention of true RCA. The authors begin by defining the events that require RCA to maximize the effect on the patient. They address not only the proactive methodologies but also the organizational paradigms that must change in order to support and sustain such activities in the interest of patient safety.Additional information about the book, including an audio visual presentation by the author is available at the PROACTÂ® website at http://www.proactforhealthcare.com

Author	p. xv
Foreword	p. xvii
Preface	p. xix
Acknowledgments	p. xxi
Recognizing and Supporting the Value of Proaction in Healthcare
The Need for Reliability Tools in Healthcare	p. 1
Background Information	p. 1
The Signals Were Stacking up in Healthcare	p. 2
The Paradigm of Patient Safety	p. 2
The Role of the Risk Manager: Industry Compared to Healthcare	p. 4
Error Rates and Technology	p. 7
Regulatory Compliance versus Patient Safety-Are They the Same?	p. 8
Creating Management Support for a Proactive Environment to Succeed	p. 11
Obstacles to Learning from Things That Go Wrong	p. 11
The Role of Executive Management in Supporting RCA	p. 12
The Role of an RCA Champion	p. 15
The Role of the RCA Driver	p. 17
Setting Financial Expectations: The Reality of the Return	p. 19
Event Prioritization Techniques
Failure Classification	p. 25
Problems versus Opportunities	p. 25
Chronic versus Sporadic Events	p. 27
Basic Failure Mode and Effects Analysis: The Traditional Approach	p. 31
Identify the Scope of the System	p. 32
Define an Unacceptable Risk in the System	p. 33
Organize the Analysis Team	p. 33
Establish Severity Ratings	p. 33
Establish Probability Ratings	p. 34
Establish Detectability Ratings	p. 34
Complete Basic FMEA Spreadsheet	p. 35
Define Subsystem	p. 36
Define Event	p. 36
Define Mode	p. 36
Develop Corrective Action Plan	p. 37
Eliminate Risk Option	p. 38
Control Risk Option	p. 38
Acceptable Risk Option	p. 39
Opportunity Analysis (OA): The Modified Approach	p. 41
Perform Preparatory Work	p. 44
Define the System to Analyze	p. 44
Define Loss	p. 44
Draw Process Flow Diagram (Block Diagram)	p. 45
Describe the Function of Each Block	p. 46
Develop Data Collection Strategy	p. 46
Collect the Data: People or Data Systems-Which Data is Most Reliable?	p. 48
Collecting Data via Interviews/Meetings	p. 48
Collecting Data from Current Data Systems	p. 50
Summarize and Encode Data	p. 51
Calculate Loss	p. 52
Determine the "Significant Few"	p. 53
Validate Results	p. 54
Issue a Report	p. 55
Understanding Root Cause Analysis
Understanding Why Things Go Wrong	p. 59
How Can RCA Be Misperceived?	p. 59
What Is Not Root Cause Analysis?	p. 60
Failure Modes and Effects Analysis (FMEA) versus Root Cause Analysis	p. 63
Opportunity Analysis (OA) and RCA	p. 64
Six Sigma and PROACT RCA	p. 66
What is Six Sigma and a Black Belt?	p. 66
Statistical Tools	p. 67
Process Mapping Tools	p. 67
Data Display Tools	p. 67
Problem-Solving Tools	p. 67
Root Cause Analysis Tools	p. 67
Process Improvement Tools	p. 68
Product/Process Interaction Tools	p. 68
Lean Thinking Tools	p. 68
What Are the Primary Differences between Six Sigma and RCA?	p. 69
Six Sigma in Industry versus Healthcare: What's the Difference?	p. 69
The PROACT Root Cause Analysis (RCA) Methodology	p. 71
Preserving Event Data	p. 73
The Error-Change Phenomenon	p. 75
The "5 Ps" Concept	p. 77
Parts	p. 78
Position	p. 78
People	p. 79
Paper	p. 81
Paradigms	p. 82
The PROACT Root Cause Analysis (RCA) Methodology
Ordering the Analysis Team	p. 89
What Is a Team?	p. 90
Team Member Roles and Responsibilities	p. 90
The Principal Analyst	p. 90
The Associate Analyst	p. 91
The Experts	p. 91
Vendors	p. 91
Critics	p. 91
Principal Analyst Characteristics	p. 92
The Challenges of RCA Facilitation	p. 92
Bypassing the RCA Discipline and Going Straight to Solution	p. 93
Floundering of Team Members	p. 93
Acceptance of Opinions as Facts	p. 93
Dominating Team Members	p. 93
Reluctant Team Members	p. 93
Going off on Tangents	p. 93
Arguing among Team Members	p. 94
Promote Listening Skills	p. 94
One Person Speaks at a Time	p. 94
Don't Interrupt	p. 94
React to Ideas, Not People	p. 94
Separate Facts from Conventional Wisdom	p. 95
Team Codes of Conduct	p. 95
Team Charter	p. 95
Team Critical Success Factors	p. 95
Team Meeting Schedules	p. 96
Analyzing the Data: Introducing the Logic Tree	p. 99
Basic Logic Tree Architecture	p. 99
The Event	p. 99
The Mode(s)	p. 101
The Top Box	p. 101
The Hypotheses	p. 101
Verifications of Hypotheses	p. 102
The Fact Line	p. 102
Physical Root Causes	p. 103
Human Root Causes	p. 103
Latent Root Causes	p. 104
Broad and All-Inclusive Analysis	p. 105
The Error-Change Phenomenon Applied to the Logic Tree	p. 107
Order	p. 107
Determinism	p. 107
Discoverability	p. 107
An Academic Example	p. 108
Hypothesis Confidence Factors	p. 113
Organizational Memory: The Logic Tree as a Troubleshooting Flow Diagram	p. 114
The Logic Tree Applied to Criminology Applications	p. 115
The Root System Contrasted to Research	p. 116
Communicate Findings and Recommendations	p. 119
The Recommendation Acceptance Criteria	p. 119
Developing the Recommendations	p. 121
Developing the Report	p. 122
Executive Summary	p. 122
Event Summary	p. 122
Analysis Findings	p. 122
RCA Methodology Description	p. 122
Root Cause Action Matrix	p. 123
Estimated ROI of Recommendations and Analysis	p. 123
Technical Analysis	p. 123
Identified Root Causes	p. 124
Types of Root Causes	p. 124
Responsibility of Executing the Recommendation	p. 124
Estimated Completion Date	p. 124
Detailed Plan to Execute Recommendation	p. 124
Root Cause Analysis	p. 124
5 Ps Data Collection Strategies	p. 124
Logic Tree	p. 125
Verification Logs	p. 125
Analysis Team Structure	p. 125
Recognition of All Participants	p. 125
Team Charter	p. 125
Team Critical Success Factors	p. 125
Recommendation Acceptance Criteria (If Applicable)	p. 125
Business Information (Optional)	p. 125
Data Collection Costs	p. 126
Hypothesis Verification Costs	p. 126
Recommendation Development and Execution Costs	p. 126
Projected Recommendation ROIs	p. 126
Projected RCA ROI	p. 126
The Final RCA Presentation	p. 127
Have the Professionally Prepared Reports Ready and Accessible	p. 127
Strategize for the Meeting by Knowing the Audience	p. 127
Have an Agenda for the Meeting	p. 128
Develop a Clear and Concise, Professional Presentation	p. 128
Coordinate the Media to Use in the Presentation	p. 129
Conduct "Dry Runs" of the Final Presentation	p. 130
Prioritize Recommendations Based on Impact and Effort	p. 130
Determine Next-Step Strategy	p. 131
Tracking for Results	p. 133
Sliding the Proactive Work Scale	p. 134
Developing Tracking Metrics	p. 134
Healthcare Equipment: IV Pump Failures	p. 134
ED: Aspirin Delays	p. 135
Patient Satisfaction Index	p. 136
Exploiting Successes	p. 137
Report Distribution	p. 138
Internal Newsletters	p. 138
Corporate Newsletters	p. 138
Presentations at Trade Conferences	p. 138
Articles in Trade Publications	p. 139
Case Histories in Clinical Journals	p. 139
Creating a Critical Mass	p. 139
Recognizing the Life-Cycle Effects of RCA on the Organization	p. 140
Conclusion	p. 141
A Software Technology to Support Proaction
Automating Proactive Analyses: The Utilization of the PROACT Suite Software Solution (Version 3.0+)	p. 145
Customizing PROACT for a Facility	p. 145
Setting Up a New Analysis	p. 146
	p. 146
	p. 146
	p. 147
	p. 148
	p. 148
	p. 148
Automating the Preservation of Event Data	p. 148
Automating the Analysis Team Structure	p. 153
Automating the Logic Tree Development	p. 153
Button Functions	p. 155
Top Box Wizard	p. 155
Add Nodes Quickly	p. 156
Present-It	p. 156
Zoom	p. 157
Undo Delete	p. 157
Center Tree	p. 157
Clear Tree	p. 157
Tab Functions	p. 157
Printing	p. 157
Build Hypothesis List	p. 157
Find in Tree	p. 158
Incomplete Outcomes	p. 158
Special Options	p. 158
Root Cause Listing	p. 158
Verification Log	p. 158
Automating RCA Report Writing	p. 160
Summary and Findings	p. 162
Recommendations	p. 162
RCA Report	p. 163
Automating Tracking Metrics	p. 164
Analysis at a Glance	p. 165
PROACT Knowledge Management	p. 167
From Theory to Practical Application
Case Studies	p. 171
Failure Modes and Effects Analysis-Interim Triage FMEA	p. 171
Lead Analysts	p. 171
Purpose of the Study	p. 171
Background	p. 171
Statement of the Problem	p. 172
Objectives	p. 172
Methodology	p. 173
Conclusion	p. 175
Recommendations	p. 177
Root Cause Analysis-Inter-Hospital Transfer Medication Error	p. 178
Lead Analysts	p. 178
Event Summary and Background	p. 178
RCA Team Charter	p. 179
RCA Methodology	p. 179
Specimen Integrity Opportunity Analysis	p. 183
Lead Analysts	p. 183
Statement of the Problem	p. 183
Objectives	p. 184
Methodology Used	p. 184
Assumptions Used	p. 184
Conclusions	p. 185
Recommendations	p. 187
Paradigm Shift Summary	p. 189
Index	p. 191
Table of Contents provided by Ingram. All Rights Reserved.

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Patient Safety: The PROACT Root Cause Analysis Approach

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