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Questions? Contact: Skip Valusek MHQP Education Chair skipvalusek@comcast

Welcome to the MHQP & HealthForce MN Quality Brownbag Room Monthly Noon Brownbag Fourth Thursday Every Month. September 23. Intro to FMEA. Welcome to the New Classroom ! https://umconnect.umn.edu/hcq/ Glad you were able to find it. Questions? Contact: Skip Valusek

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Questions? Contact: Skip Valusek MHQP Education Chair skipvalusek@comcast

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  1. Welcome to the MHQP & HealthForce MN Quality Brownbag Room Monthly Noon Brownbag Fourth Thursday Every Month September 23 Intro to FMEA Welcome to the New Classroom ! https://umconnect.umn.edu/hcq/ Glad you were able to find it. Questions? Contact: Skip Valusek MHQP Education Chair skipvalusek@comcast.net Slides are posted at: http://www.healthforceminnesota.org/pages/Programs/courses.html

  2. Hopefully you provided your name & organization when you signed in. If so: Just say Hi in the Chat Pod and we’ll capture your name and organization in the log. If not: identify yourself and organization in the Chat Pod to the left of your screen. Register your Attendance

  3. Rural / Outstate ? Metropolitan area ? Organization that has (or serves) both ? Poll: Who is Attending this Session ? 4 3

  4. Healthcare system Hospital Clinic or Clinic System Long term care Healthplan Homecare / Hospice A Quality Support Organization Other ? (e.g. MCM ) Poll: Who is attending: Organization Type ? 3 6

  5. 1 2 3 4 5 6 7 >7 Poll: How many total participating in your room ? 8 1 1

  6. I am a healthcare quality professional and am interested in additional education. I am a healthcare professional interested in developing quality skills as a core competency. I am a healthcare professional interested in learning more about healthcare quality. Poll: What do you hope to gain by participating? 8 3

  7. www.patientsafety.gov

  8. Poll:How are your FMEA’s launched ? • Events in the news and leadership response : • “Could that happen here?” • 2. Board or Senior Leadership initiated concerns • 3. Quality surfaces the analysis • 4. We must do one periodically per TJC • so we search for candidates. • 5. Other (identify in Chat Pod) 9 1

  9. FMEA origins:Fault Tree Analysis • An engineering tool • Yes, you are engineering systems The difference in healthcare is the number of humans (and therefore variables) in the system !

  10. FMEA origins • Think of it as a Root Cause Analysis before the fact. • A consulting firm calls the process its “pre-mortem” and is used for projects as well as processes: • “Where is this likely to fail and why” • “What assumptions are we making” Assumption surfacing and management

  11. FMEA similarity to other tools:Cause-and-Effect /Ishakawa / Fishbone Diagram(from CPHQ exam prep materials)

  12. RCA & Fishbone Common Categories • Process • Communication • Information • Equipment • Environment • overall physical • at the time • Training/Education/Competency

  13. James Reason’s swiss cheese model of failure points and defenses

  14. Failure Mode and Effects Analysis (FMEA)-preventive approach used to identify failures & opportunities for error Traditional techniques adapted from industry; department of Veterans Affairs created Healthcare FMEA (HFMEA) www.patientsafety.gov Six main steps FMEA: 58

  15. 1. Define topic & process to be studied 2. Convene interdisciplinary team with content/process experts 3. Develop flow diagram of process & sub-processes 4. List all possible failure modes of each sub-process 5. Analyze each failure mode & determine action to eliminate, control, or accept 6. Identify corresponding outcome measure FMEA 58

  16. Poll: How many of you/your organizations have done a complete FMEA using a form similar to the VA template ? • We use the template routinely at its full depth. • We’ve used the template occasionally at its full depth • We use the template at its full depth for major concerns • We have not used the template or its detail • Other (identify in the chat pod) 2 2 3 2

  17. FMEA Rating Scales

  18. Update wrong record • Update wrong med • Lost med • Wrong patient

  19. Polls: How many of you have participated in an FMEA for: 3 • Medication Delivery • Lab • Radiology • EHR • Falls • Pressure Ulcers • Transfusions 3 3 1 Clinical documentation process 0 2 1 Other: SCIP; Discharge Instructions; Advance Directives

  20. Poll: How do you feel about implementation of analysis recommendations ? • We routinely implement at least one of the findings across our system. • We implement findings but it isn’t routine and generally doesn’t make it across the system. • Other (identify in chat pod) 6 1

  21. Poll: How do you share the results of your FMEA findings ? • Through MAPS • Internally through Quality communication processes • Both of the above • Other (identify in chat pod) 0 7

  22. Questions ?

  23. Welcome to the MHQP & HealthForce MN Quality Brownbag Room Monthly Noon Brownbag Fourth Thursday Every Month October 28th tbd Contact Skip if you’d like to be a panel member and/or have brownbag topics Questions? Contact: Skip Valusek MHQP Education Chair skipvalusek@comcast.net Slides are posted at: http://www.healthforceminnesota.org/pages/Programs/courses.html

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