Just Culture Application – Event Investigation Part 2 “Rules of Causation”

1. Just CultureApplication – Event InvestigationPart 2“Rules of Causation” Stephanie Sobczak Quality Improvement Manager WHA

2. Welcome New Teams! Jill and Stephanie will host a special conference call for new Just Culture teams for an orientation to the initiative and Q & A April 17, Wednesday @ Noon Call: 1-800-747-5150 Code: 29766

3. Just Culture Teams

4. Today’s Call Application – Event Investigation – Part 2 • Event Investigation – brief review • Examining Types of Causes • Understanding Rules of Causation • Case Examples • Next 30 days Please be certain your phone lines are muted or computer speakers turned down to allow for open discussion on the phones

5. Past 30 Days

6. Event Investigation Review

7. The Basics of Event Investigation Increasing value

8. The Basics of Event Investigation Understanding the link between the outcome and behavioral choices • Explain human errors • What performance shaping factors impact these? • System • Personal Performance • Explain at-risk behaviors • Why was the decision made? • How prevalent is the behavior?

9. Reviewing Your Existing Processes Increasing value

10. Event Investigation What is the role of event investigation in the management of risk? Single Event: To Explain To Predict To Solve To Allocate Responsibility Systemic Investigation: To inform the organization of dominant risks, causal failure modes, and rates

11. Common Traps Guessing or Assuming “I’ve seen this before….” Not doing an investigation Not talking directly to the people involved Arriving at a conclusion too early

12. Examining Types of Causes

15. Cause vs. Correlation

16. 5 Rules of Causation Causal Statements must clearly show the ‘cause and effect’ relationship Negative descriptors may not be used in causal statements Each human error should have a preceding cause Each ‘at-risk’ behavior/violation, or procedural deviation, should have a preceding cause. Failure to act is only causal when there was a pre-existing duty to act.

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24. Case Study Review

25. Causal Diagram Process

27. Case A - Housekeeping Example

29. Case B – Central Venous Catheter

32. Group Discussion

33. Event Investigation Hands On Practice Example Prior to May 1 webinar Using an in-house scenario, have your JC team walk thru an event investigation process using what you have learned Be prepared to share with the group what insights you discovered as a result.

35. The Next 30 Days

36. Thank You! Questions? May 1st Just Culture Webinar 10-11 am Coaching At-Risk Behavior