Critical Event Review (Root Cause Analysis)

1. Critical Event Review(Root Cause Analysis) Hutchinson Area Health Care December 2008

2. What are we going to cover? • What is Critical Event Review (CER)? • Brief Overview • Reasons for conducting a Critical Event Review • Hutchinson Area Health Care’s use in Long Term Care - Process • Story

3. What is a Critical Event Review? • A process that uses a systems approach for identifying the basic causes for an undesirable event or problem • Focus on the process and systems, not individuals • Uses the technique of asking the “why” question multiple times • A confidential process

4. Reasons to do a Critical Event Review • It is a review process used to uncover the facts and the underlying story that led up to the event • Identification of contributing factors • More in-depth understanding of the sequence of events • Assists in improving facility systems/processes • Promotes proactive Action Plan development to assist in preventing recurrence • Resident Safety • Reduce the harm to residents by increasing the resilience of our responses when the event repeats

5. Events where use of CER could be considered… • Events with serious outcome for the resident • Repeating incidents • Near Misses/Good Catches • Examples: • Falls • Medication Errors • Plan of Care not followed

6. CER Selection Criteria • Initially Joint Commission driven • Sentinel event standard requiring RCA’s to be done • Was applied to CMS sentinel event criteria • Based on event data analysis • Highest event (falls) • Severity • Resident safety focus – reduction of harm • Future – working to be proactive – near miss

7. Immediate Actions • Ensure resident and staff are safe • Notification of Administration • Assess need for additional resources • Secure equipment, tubing, medications, involved in event • Communication to resident and family

8. Immediate Actions (continued) • Complete documentation by the care provider • Medical Record: Facts- Objective data/description of event • Event/Incident Report • Institute an immediate corrective action if possible • Staff Notes (not part of the medical record) • Coach staff: record when resident last seen, what they heard, room arrangement, location of equipment, your response • Who, What, When, Where, Why • Staff notes need to turned into Quality Department or Quality Manager • Drawings/Pictures

9. CER Meeting Steps • Set up initial meeting 48 to 72 hours post event (if not sooner) • Who sets up the meeting • Identify and invite key players • Won’t compromise resident safety

10. Key Players • Staff from departments/units directly and indirectly involved in the event • Nursing Administration • Medical Director • Physician/Provider as needed • Quality Representative • Administrator • Facilitator • Others as identified

11. CER Meeting Steps (continued) • Coaching Staff • May be initiated prior to meeting being set up if member has not participated before • Participation in the CER is an opportunity to learn • Chance for staff to tell their story • Emphasis is on improving the system • Just in Time Training

12. Meeting Preparation • Room with comfortable atmosphere • Flip Chart and Markers • Kleenex • Coffee/Water/Treats • Medical Record/Reports • Any of the pre-work documentation • Staff Notes • Chart Review • Lead nursing completes • Time line of the event

13. Facilitator • Team training/group skills • Clinical background can be helpful, but not required • Listening skills – use facilitation to uncover the story behind the event • Analytical skills – conversational/timeline versus investigation data gathering • Positive – sense of humor – sensitive – deal with emotions – awareness • Strong boundaries • Brings people back to focus • Ability to manage emotion at the table – fear/anger • Is able to identify and draw out people • Engages the entire team to give their perspective • Need to support everyone’s style

14. Recorder • Recorder – listen to how they are saying, as well as what they are saying • Facilitator may be the recorder as well • Would recommend a recorder be available

15. Meeting Format • Introductions and Ground Rules • Confidentiality • Titles left at the door - all members need to be active participants • There are no bad questions • Systems and process focus • Not blaming/finger pointing • Want to foster creativity • “You” have the solutions • Brief orientation to CER

16. CER Meeting in Progress • Tell the story • Brief overview of resident • Start with the person who found resident • Try to obtain details of what happened • What did you see? • Encourage people to share • Facilitator stands in front and captures data on white flip chart • “BIN” list – gives credence, but allows facilitator to move back to subject • Try to identify opportunities /gaps as the story is presented • Why, Why, Why? • How were they laying? Where was the wheel chair? • What is the purpose having the wheel chair across the room?

17. Use of Triage Questions • Helps team understand event • Assures thoroughness of investigation – “buckets” • Human factors • Staffing • Communication/Information • Equipment/Environment • Uncontrollable external factors • Training • Rules/Policies/Procedures • Barriers

18. Forms

19. CER Meeting cont. • Identification of factors that may have influenced the circumstances that led to the event • Identification of system/process gaps • Opportunities identified for improvement • Feedback from participants on how systems can be improved is critical • Is there anything that we could have been done differently? • Development of an action plan – based on findings – with target dates and responsible party listed • Monitoring/measurement plan as indicated • (Critical Event Review Corrective Action Plan -to be covered more in depth in later presentation) • Follow-up

20. Spread the Success/knowledge • Share with staff and Administration • Need to go beyond interdisciplinary care team • Potential: • Share learnings and collaborate with other facilities

21. Critical Event Review Summary • To be thorough, a RCA must include: • Determination of human and other factors • Determine related processes and systems • Analysis of underlying causes and effects – series of why’s • Identification of risks and their potential contributions

22. Questions? Thank you!