IHI Virtual Expedition

1. 03/07/2018 These presenters have nothing to disclose James Bagian, MD, PE Terry Fairbanks, MD, MS, FACEP, CPPS IHI Virtual Expedition Expedition: Root Cause Analyses and Actions (RCA2) Session #4 - Event Review: Finding and Mapping the Facts

2. Today’s Host Krissy Cronin Project Coordinator Institute for Healthcare Improvement Boston, MA

3. Audio Broadcast You will see a box in the top left hand corner labeled “Audio broadcast.” If you are able to listen to the program using the speakers on your computer, you have connected to the audio broadcast.

4. Phone Connection (Preferred) • To join by phone: • Click on the “Participants” and “Chat” icon in the top, right hand side of your screen to open the necessary panels • Click the button on the right hand side of the screen. • You can select to call in to the session, or to be called. If you choose to call in yourself, please dial the phone number, the event number and your attendee ID to connect correctly.

5. WebEx Quick Reference Please use chat to “All Participants” for questions For technology issues only, please chat to “Host” Raise your hand Select Chat recipient Enter Text

6. Expedition Lead Joellen Huebner Project Manager Institute for Healthcare Improvement Boston, MA

7. Today’s Agenda • Introductions • Event Review: Finding and Mapping the Facts • Action Period Assignment

8. Action Period Assignment • Download and review RCA2: Improving Root Cause Analyses and Actions to Prevent Harm • Share your questions and experiences on the RCA2ListServ

9. Faculty: Course Directors James Bagian, MD, PE Director, Center for Healthcare Engineering and Patient Safety (CHEPS) University of Michigan Rollin (Terry) Fairbanks, MD, MS, CPPS Asst.VP, Ambulatory Quality & Safety, MedStar Health Founding Director, National Center for Human Factors in Healthcare

10. Faculty Seth Krevat, MD, FACP Assistant Vice President, Safety, MedStar Health Assistant Professor of Clinical Medicine, Georgetown University School of Medicine Kathryn Kellogg, MD, MPH, CPPS Assoc. Medical Director, Quality & Safety, MedStar Health Assoc. Medical Director, National Center for Human Factors in Healthcare

11. Today’s Learning Objectives At the end of this session, participants will be able to: • Identify and utilize tools for effective interviewing • Describe the process of flow diagramming and its importance to event review

12. Interviewing: The Purpose • Discover information about what happened and why that will lead to identification of system issues and effective, sustainable actions • Gain expertise required for the review not already represented by those on the RCA2 team • Gain a more complete understanding of the event • Engage individuals involved in the event • Engage patients and family members who were involved in the event

13. The Fundamental Question The fundamental question of this process is not “where did people go wrong?” but “why did their action make sense to them at the time?” Dekker S. The Field Guide to Understanding Human Error. Burlington, VT: Ashgate Publishing, 2006.

14. Interviewing Best Practices: Staff • Interviews should be conducted in person, one-on-one if possible, in a setting that is comfortable and safe for the interviewee • Supervisors should be alerted of the interview, but should not be present during the interview • Explain that the interview is being conducted to identify and implement system-level corrective actions and prevent future occurrence • Request permission to take notes and explain what those notes will be used for RCA2: Improving Root Cause Analyses and Actions to Prevent Harm, Appendix 3

15. Interviewing Best Practices: Patients • Patients should be allowed to have family members present during their interview • Conduct the interview in a location that is comfortable and acceptable to the patient • Limit the RCA2 team members conducting the interview to one or two individuals • Express to the patient/family that you are sorry the event occurred and are working to identify system-level solutions so the event does not happen again • Request permission to take notes and explain what those notes will be used for RCA2: Improving Root Cause Analyses and Actions to Prevent Harm, Appendix 3

16. Interviewing Techniques • Start with broad, open-ended questions and then narrow them down to specific clarifying questions, as needed • Use active listening and reflect what is being said • Keep an open body posture, good eye contact, and nod appropriately • Demonstrate empathy and patience • Thank the interviewee at the conclusion of the process and provide your contact information and resources available for support RCA2: Improving Root Cause Analyses and Actions to Prevent Harm, Appendix 3

17. Remember: • Interviewing requires advance preparation and thought by the RCA2 team • Interviewing is a skill! • Be a good listener • Individual interviews, one-on-one • Time for empathy and compassion • Understand why actions made sense at the time

18. Flow Diagramming • Flow diagrams provide a graphical representation of the event as it happened • Flow diagrams or timelines assist the RCA2 team in understanding: • How the event occurred • Gaps in knowledge that can be filled through additional factfinding (internal and external) • Flow diagrams are used to compare what should have happened with what actually happened

19. Final Flow Diagram Example (pt.1) RCA2: Improving Root Cause Analyses and Actions to Prevent Harm, Appendix 4 All events appearing in this flow diagram are fictitious. Any resemblance to real events is purely coincidental.

20. Final Flow Diagram Example (pt.2) RCA2: Improving Root Cause Analyses and Actions to Prevent Harm, Appendix 4 All events appearing in this flow diagram are fictitious. Any resemblance to real events is purely coincidental.

21. Questions/Discussion Raise your hand Use the chat

22. Action Period Assignment Download and review RCA2: Improving Root Cause Analyses and Actions to Prevent Harm Share your questions and experiences on the RCA2ListServ

23. Expedition Communications • All sessions are recorded • Materials are sent one day in advance • Listserv address for session communications: exprootcauseanalyses@ls.ihi.org • To add colleagues, email us at info@ihi.org

24. Session 5 Event Review: Determining the Cause and Effective Actions Terry Fairbanks, MD MS CPPS Terry.Fairbanks@MedStar.Net James Bagian, MD PE jbagian@med.umich.edu Kate Kellogg, MD MPH Kathryn.M.Kellogg@MedStar.net Seth Krevat, MD FACP Seth.Krevat@MedStar.net Wednesday, March 21, 2018 | 12:00 PM ET

25. Schedule of Calls Session 1 – Understanding RCA2: The Process of Event ReviewDate: Wednesday, January 24, 12:00 - 1:30 PM Eastern Time Session 2 – Identifying and Classifying Events for Review DateDate: Wednesday, February 7, 12:00 - 1:00 PM Eastern Time Session 3 – Event Review: Determining the Team and Engaging the PatientDate: Wednesday, February 21, 12:00 - 1:00 PM Eastern Time Session 4 – Event Review: Finding and Mapping the Facts DateDate: Wednesday, March 7, 12:00 - 1:00 PM Eastern Time Session 5 – Event Review: Determining the Cause and Effective Actions Date: Wednesday, March 21, 12:00 - 1:00 PM Eastern Time Session 6 – Implementation, Measurement, and Feedback Date: Wednesday, April 4, 12:00 - 1:00 PM Eastern Time

26. Thank You! Please let us know if you have any questions or feedback following today’s Expedition webinar. Joellen Huebner jhuebner@ihi.org Krissy Cronin kcronin@IHI.org