Standard Cause Analysis Model Norton Healthcare

1. Standard Cause Analysis ModelNorton Healthcare Kelly Johnson, DNP, RN, CPPS November 2018

2. BackgroundRationaleSignificance • 1 in 4 American families are affected by healthcare harm in the U.S. • As many as 16% of Americans will experience preventable healthcare harm • Between 100K and 400K Americans die each year from preventable healthcare harm • If ranked, patient safety events would be the 3rd leading cause of death in the US • A medication error affecting a child occurs every 8 minutes in the US (Denham et al., 2012; Macrae, 2008)

3. Why Here? Why Now? • Reaching for Zero strategic plan to eliminate preventable healthcare harm • Significant variation in process • Voice of customer revealed opportunities for improvement • Punitive feeling meetings • Not getting to real causes • Lack of accountability for actions/demonstration of real change • Repeat events

4. International Guidelines

5. RCA2 White Paper

6. Graduated Approach • Written into strategic plan over multiple years • Foundational work on root cause analyses: • DMAIC PI methodology • Lewin’s Change Theory • Team included people from pilot hospital as well as system for planned replication • Piloted for 90 days at largest hospital with specialized services • Staged replication throughout rest of healthcare system over several months • Control plan still in place • Current focus on other types of cause analysis

7. Cause Analysis Model • Root cause analysis • Apparent cause analysis • Aggregate analysis • Common cause analysis

8. Standard Root Cause Analysis Model

9. Standard Root Cause Analysis Model

10. Standard Root Cause Analysis Model

11. Standard Root Cause Analysis Model

12. Apparent Cause Analysis • Smaller, faster review • Conducted at unit/department with their leaders • May include people involved • Typical tools utilized: • Causal Factor Fishbone • Cause Analysis Interviewing Tips • Cause Analysis Probing Questions by Causal Factor • Event Timeline Flowsheet

13. Lessons Learned • Stakeholder support was crucial • Organizational assessment and gap analysis was needed to know where to start and what level of change could be accepted • Critical to have investigation completed before analysis meeting • Leaders must be engaged in action item tracking and accountability

14. Current State • Monitor RCA process through control plan • Extended education on ACA process • Trial of risk grading and aggregate ACA with pharmacy on no-harm medication errors • Common cause analysis with RCAs 2016-2018

15. References • Dearholt, S., & Dang, D. (2012). Johns Hopkins nursing evidence - based practice: Model and guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International. • Denham et al., (2012). An NTSB for healthcare - learning from innovation: Debate and innovate or capitulate. Journal of Patient Safety, 8(1), 3-14. • Parker, J. (Ed.). (2015). Root cause analysis in healthcare: Tools and techniques (5th ed.). [Adobe Digital Edition]. Retrieved from www.jcrinc.com • Macrae, C. (2008). Learning from patient safety incidents: Creating participative risk regulation in healthcare. Health, Risk & Society, 10(1): 53-67. • Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management, 20, 32-37. • Shirey, M. (2013). Strategic leadership for organizational change. Journal of Nursing Administration, 43, 69-72. *Full evidence table for project available separately