1. Quality Improvement and Patient Safety Forum

2. This is a peer review document subject to the confidentiality requirement of the New Mexico Review Organization Immunity Act, NMSA § (2003). Unauthorized disclosure is strictly prohibited and subject to fines.
This is to protect us legally – Since this is a QI case we can talk about it freely and what we say/share here cannot be used in a court of law.

3. Objectives Perform a system-based root cause analysis
Identify one system-level intervention to offer to leadership

4. Last time on QIPSF…
Check in the the QI group to see if there are any updates on prior cases…

5. ROAD MAP
Identify one outcome
Costs of this outcome?
Perform a root cause analysis in groups
Pick one systems issue
System-level interventions in groups
Prioritize based on effort-yield

6. (Focused case presentation; about 10 minutes)
- Tailor the case to the chosen outcome (this will make data collection/case presentation more effective and efficient)
- No need for minutiae just the facts!
- Try for less/no bullets or written words = less cognitive overload.
- Some of the best cases are narratives (with no data on the PPT slides)

7. The Outcome
(Choose one specific outcome to focus on for your RCA)

8. What were the costs or potential costs of of this adverse outcome?
(Less than 5 min)

9. Systems-Based Root Causes?
People
Policies
Outcome
Process
Place
(Small Group Exercise: 5-6 people per group max - 10 min)
Please choose a RCA method e.g. Fishbone Diagram or the The “5 Whys”
For the moment… try to avoid solutions

10. RCA Discussion
(Large Group Discussion - 5 minutes)

11. Potential Systems-Level Interventions?
(Small Group Exercise: 5-6 people per group max – 10 min)
Think about interventions

12. Potential Systems-Level Interventions?
(Large Group Discussion – 5 min)

13. Effort vs Yield?
Yield
Effort

14. Our Suggested Interventions?
Ideally 1 suggestion for clinical leadership

15. Objectives Perform a system-based root cause analysis
Identify one system-level intervention to offer to leadership

16. References
Szostek, Jason H., et al. "A systems approach to morbidity and mortality conference." The American journal of medicine (2010):