1. JUST-IN-TIME TRAINING
ROOT CAUSE ANALYSIS
JUST-IN-TIME TRAINING
STRATEGIES AND TOOLS
FOR TEAM SUCCESS
COL Judy L. Powers
Chief, Quality Operations
Quality Management Directorate
U.S. Army Medical Command
Explain what quality was nearly 20 years ago
Show Sweatshirt with logo and--PFNNKA
How that mentality has stayed with us.

2. LEADERSHIP ROLE Ensure SAC Score identified Charter RCA Team
SAC 3 events require RCA
Charter RCA Team
Clearly Identify Team Timeline
Ensure RM completes RCA Form # 1-13
Involvement and Team Support
IM/IT
Incentives to encourage participation
THANK the reporter(s)

3. FACILITATE TEAM SUCCESS
Provide resources & time to accomplish goal
Members empowered by task
Identify members & roles
Include process owner(s) input
Knowledge and commitment to PI (champions)

4. RCA TEAM RCA Facilitator - Process Expert (PI tools)
Team Leader - Content Expert (in charge)
RCA Advisor & Team Leader may need to work off-line to facilitate progress
Team Members (3-5)
Include all levels of personnel closest to event
Include someone w/ decision making authority; process owners

5. GETTING STARTED Team Introductions Clarify Roles & Responsibilities
Establish Ground Rules
Communication Strategies
Meeting Schedules
Team Assignments
Ensure all time spent documented
Recommended several steps to unify the Nation in improving the quality of healthcare
Report noted that many organizations, including several Federal agencies were involved in important efforts to improve quality, but the lack of coordination made it difficult for healthcare providers and was confusing to the public

6. RCA PROCESS (Meeting 1) Initial Understanding of Event (RCA Form #14)
Develop Flow Diagram(s)
Sequence of events
Actual process as documented
Mark possible contributory items
Don’t allow folks to “jump to action”
Parking Lot

7. RCA PROCESS (Meeting 1) Organize the Event (see handout)
Objective “reporters view” of event (highlights of sequence of events)
Identify needed resources & information
Identify personnel to interview
Identify needed references
RCA Form Section 14-17

8. RCA PROCESS (Meeting 1) Identify Relevant Processes
What processes are associated w/ event?
What area/service(s) impacted?
Triage Questions - “Starting Point”
Patient Assessment
Staff Training/Competency
Equipment
Lack of Information
Rules/Policies/Procedures
Barriers
Personnel/Personal Issues

9. RCA PROCESS (Meeting 1) Brainstorm Information Required
Identify all possible causes & potential problems
Identify information gaps
Focus on processes NOT people
Information Required
Identify Responsible Team Member
Timeline for Acquiring

10. RCA PROCESS (Meeting 2 & 3)
Identify final sequence of events
(RCA Form # 18)
Identify Root/Contributing Causes (RCA Form #19 - cause/effect diagram)
Go for the obvious, then the specific
Focus team to identify process problems
Identify proximate factors, then ask WHY to drill down to root causes
Neutral party helpful in assuring ask WHY enough
5 Rules of Causation (causal statements)

11. ROOT CAUSES Consider Using other PI & Statistical Tools
Multi-voting
Pareto Charts
Scatter Diagrams
Control Charts
Organize List of Root causes (RCA Section 19)
Verify w/ JC “minimum scope” document
Prioritize
Patient Safety
Applicable to Multiple Sites
May be Resource Driven
Retain Explanations for those Can’t Do

12. RCA PROCESS (Meeting 3 & 4)
Develop Action Plan (RCA Form # 23)
Generate at least one corrective action for each identified RC
Prioritize
Identify Eliminate, Control, Accept
Linked to Measurement
Time-line/follow-up dates identified
Identify how best to communicate findings (RCA Form # 22)

13. MEASUREMENT STRATEGY Set Reasonable/Attainable Goals
Actions must be measurable
Consider who/how/what/when action will be measured
Consider pilot study for new clinical process
Designate reporting/oversight responsibility
Working Document - NOT just for JCAHO

14. IMPLEMENT IMPROVEMENTS
RCA Action Plan Table assigns who & when
Funding Concerns are raised as priority to Command
Agreement from all team members & departments
Check Implementation Progress
Risk Manager follow-up per timeline
Timeframe 6 months & 1 year
Closure at 1 year

15. ACT TO MAINTAIN Communicate findings to reporter (RCA Form # 17)
Use SE/Near Miss data as learning experience for MTF
Incorporate new policies/ procedures in departments
Incorporate lessons learned into orientation

16. PUTTING IT ALL TOGETHER
Benefits to practicing with a “Planned Root Cause Analysis” process
Avoids crisis mode operations
Provides focused, systematic approach to problem solving
Reduces rework
Appreciate what can be done in 45 days

17. ROLL-UP 3 - 5 Team Meetings (2 hr) Team Leader/Facilitator
Meeting 1 - Flow Diagram/Contributing Causes
Meeting 2/3 - Contributing Factor Table
Meeting 3/4 - Action Plan
Meeting 5 - Communication/Feedback Plan
Team Leader/Facilitator
May need meet off-line
Monitor action plan progress/effectiveness

18. RESOURCES SE/Near Miss Management Web Sites
JC Sentinel Event Alerts
JC Sentinel Event Hotline (630)
Web Sites
JCAHO -
National Patient Safety Foundation -
Institute of Safe Medication Practices -
Scholtes, Joiner & Streibel, The TEAM Handbook, 2nd Edition, 1996.

19. Make the Safest Way the Easiest Way!
CONCLUSION
Make the Safest Way the Easiest Way!
THANK YOU!
COL Judy L. Powers
(210)