Standard Cause Analysis Model Norton Healthcare Kelly Johnson, DNP, RN, CPPS November 2018

Background Rationale Significance 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 Problem has been known for 15+years; exists at international level- not specific to NHC. (Denham et al., 2012; Macrae, 2008)

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 Made a commitment to improve via our Reaching for Zero strategic plan. This project is part of one of the major domains of Reaching for Zero on event management.

International Guidelines System Analysis of Clinical Incidents: The London Protocol (2001) WHO Draft Guidelines for Adverse Event Reporting & Learning Systems (2005) Patient Safety Handbook, VA (2011) Respectful Management of Serious Clinical Incidents, IHI (2011) Serious Safety Events: Getting to Zero, ASHRM 2012 Optimizing RCA & Organizational Learning, HPI, LLC (2014) RCA2: Root Cause Analysis & Actions to Prevent Harm, NPSF (2015) Several set of guidelines; many very old but still had valid recommendations because organizations have been so slow to change.

RCA2 White Paper More weight to most recent national guidelines. Were able to put most of these recommendations in place.

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 Pilot facility: Norton Hospital was chosen because: Size and opportunity to test changes quicker than small facilities Leader engagement level in patient safety Culturally ready for change

Cause Analysis Model Root cause analysis Apparent cause analysis Aggregate analysis Common cause analysis

Standard Root Cause Analysis Model Planned team response including executive sponsor Immediate response checklist Meeting 1 with checklist Investigation launched Identification Determine what, why & how Meeting 2, cause analysis with flow chart timeline Core team and peer representatives and subject matter experts Analysis Executive sponsor assigns review of literature/standards Meeting 3 for action plan Measures of effectiveness Summary sheet for feedback and learning Change

Standard Root Cause Analysis Model Planned team response including executive sponsor Immediate response checklist Meeting 1 with checklist Investigation launched Identification

Standard Root Cause Analysis Model Determine what, why & how Meeting 2, cause analysis with flow chart timeline Core team and peer representatives and subject matter experts Analysis

Standard Root Cause Analysis Model Executive sponsor assigns review of literature/standards Meeting 3 for action plan Measures of effectiveness Summary sheet for feedback and learning Change

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

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

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

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