Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient Safety

Description

The book follows a proven training outline, including real-life examples and exercises, to teach healthcare professionals and students how to lead effective and successful Root Cause Analysis (RCA) to eliminate patient harm. This book discusses the need for RCA in the healthcare sector, providing practical advice for its facilitation. It addresses when to use RCA, how to create effective RCA action plans, and how to prevent common RCA failures. An RCA training curriculum is also included. This book is intended for those leading RCAs of patient harm events, leaders, students, and patient safety advocates who are interested in gaining more knowledge about RCA in healthcare. Cover Half Title Title Copyright Contents Preface Acknowledgments Authors Part I Building an Understanding of RCA Chapter 1 The Need for Root Cause Analysis (RCA) 1.1 Why Investigate Healthcare Unintended Events? 1.2 Caring for Caregivers 1.3 Systems Approach 1.3.1 Aviation’s Breakthrough 1.4 Leadership Support for a Culture of Safety 1.4.1 Leadership Responsibility for RCA 1.5 Patients at the Center 1.6 Questions to Consider Chapter 2 Forms of Analysis 2.1 Troubleshooting 2.2 Simple Problem-Solving 2.3 Complex Problem-Solving 2.4 A3 Thinking 2.5 Whys 2.6 Failure Modes and Effects Analysis 2.7 Case Quality Review 2.8 Apparent-Cause Analysis 2.9 Logic Tree 2.10 Meta-Analysis 2.11 Peer Review 2.12 Morbidity and Mortality Conference 2.13 Summary of the Different Forms 2.14 Selecting the Form of Analysis 2.15 Forms of RCA 2.15.1 Telephone Cutover Disaster: A Case Study 2.15.2 5 Whys, Fishbone, and Bimodal Methods 2.16 Questions to Consider Chapter 3 Pre-Work for an RCA Team Meeting 3.1 Early Investigation and Preservation of Evidence 3.2 Tasks in Preparation 3.2.1 Defining Serious Safety Events 3.2.2 Ordering the Team 3.2.3 The Chronology 3.2.4 The Logic Tree Top Box 3.2.5 Top Boxes with Two Modes 3.2.6 Logistics 3.3 Exercise 1: Chronology 3.4 Summary 3.5 Questions to Consider Chapter 4 Creating the Logic Tree 4.1 Logic Tree Root Causes 4.1.1 Exercise 2: Types of Roots 4.2 Logic Tree Hypothesizing 4.2.1 Hypotheses 4.2.2 How Could versus Why 4.2.3 Two Approaches to Hypothesizing 4.2.4 Boolean Logic 4.3 Risks Associated with Hypothesizing 4.3.1 Categories versus Hypotheses 4.3.1.1 Countermeasure 4.3.2 Latent Roots as Hypotheses 4.3.2.1 Countermeasure 4.3.3 Hypotheses Are Too Broad 4.3.3.1 Countermeasure 4.3.4 Hypotheses Are Too Narrow 4.3.4.1 Countermeasure 4.4 The Importance of Facilitating Hypothesizing 4.4.1 Exercise 3: Hypothesis Generation 4.5 Verifying and Testing the Logic Tree 4.5.1 Verifications 4.5.1.1 Parts 4.5.1.2 Position 4.5.1.3 People 4.5.1.4 Paper 4.5.1.5 Paradigms 4.5.2 Documenting Verifications 4.5.3 Strength of the Evidence 4.5.4 Confidence Levels 4.5.5 Chain of Causation 4.5.6 Exercise 4: Logic Tree 4.6 Latent Roots versus Contributing Factors 4.7 Telling the Story 4.8 Summary 4.9 Questions to Consider Chapter 5 Effective Action Plans 5.1 The Reality of Most RCA Action Plans 5.2 A New and Novel Approach to RCA Action Planning 5.3 Elements of the Action Plan 5.4 Rigor Testing 5.5 Action Plan Template 5.5.1 Action Plan Metrics 5.6 Improvement Tools 5.6.1 Standardized Work 5.6.2 Training Matrix 5.6.3 Process Observation 5.6.4 Abnormality Tracker 5.6.5 Rounding 5.7 Summary 5.8 Questions to Consider Chapter 6 RCA Facilitation 6.1 Ethics of Inquiry 6.2 Practical Aspects for Facilitation 6.2.1 Paper Based or Software 6.2.2 Skill Development 6.2.3 Shared Facilitation 6.2.4 Team Focus 6.2.5 Active Facilitation 6.2.6 Facilitating the Logic Tree 6.3 Summary 6.4 Questions to Consider 6.5 Exercise 5: Logic Tree 2 Part II Root Cause Analysis Champions Chapter 7 RCA Standardized Work by Role 7.1 Standardized Work by Role 7.1.1 Executive Sponsor 7.1.2 Process Owner 7.1.3 Direct Caregiver 7.1.4 Physician Leader 7.1.5 Subject Matter Experts 7.1.6 Support Services 7.2 Implementing Standardized Work 7.3 Summary 7.4 Questions to Consider Chapter 8 Barriers to RCA and Their Countermeasures 8.1 How Could RCAs Fail? 8.2 Countermeasures 8.2.1 RCA Facilitation 8.2.2 Executive Sponsors 8.2.3 Organization 8.2.4 RCA Evaluation Tool 8.3 Summary 8.4 Questions to Consider Chapter 9 Strategies for No Repeat Events 9.1 Repeat Events Defined 9.2 Strategies for No Repeat Events 9.2.1 Review of Action Plans within the Department/Unit 9.2.2 Review of Mode Categories across the Organization 9.2.2.1 Trending at the Event Level 9.2.2.2 Trending at the Mode Level 9.2.2.3 Trending at the Latent Root Cause Level 9.2.2.4 Spreading Action Plans 9.2.3 Systems Reliability 9.3 Summary Chapter 10 Teaching RCA 10.1 Training Pre-Work 10.2 Training Guide 10.2.1 Training Outline 10.2.1.1 Day 1 10.2.1.2 Day 2 10.2.2 Teacher’s Guide 10.2.2.1 Training Exercise #1 10.2.2.2 Training Exercise #2 10.2.2.3 Training Exercise #3 10.2.2.4 Student Handout Training Exercise #1: Train Derailment 10.2.2.5 Student Handout Training Exercise #2: Canceled Surgery References Appendix 1: Logic Tree for Train Derailment Exercise Appendix 2: Logic Tree for Canceled Surgery Exercise Index