1. Just Culture Application – Event Investigation Part 2 “Rules of Causation” Stephanie Sobczak Quality Improvement Manager WHA 1

2. Welcome New Teams! Jill and Stephanie will host a special conference call for new Just Culture teams for an orientation to the initiative and Q & A April 17, Wednesday @ Noon Call: 1-800-747-5150 Code: 29766 2

3. Just Culture Teams 3 Wave 1 Aspirus Wausau Baldwin Area Medical Center Fort Healthcare Gunderson Lutheran Langlade (Antigo) Memorial Health Cntr (Medford) Riverside Medical Center Sacred Heart (Eau Claire) Sauk Prairie St. Joseph’s (Chippewa Falls) UWHP Watertown Wave 2 Aurora Medical Center (Kenosha) Holy Family (Manitowoc) Hudson Hospital Rusk County Memorial (Ladysmith) Upland Hills Health (Dodgeville) “Monitoring” Beaver Dam Community Black River Memorial Calumet Medical Center (Chilton) Edgerton Hospital Mercy Hospital (Janesville)

4. Today’s Call Application – Event Investigation – Part 2 Event Investigation – brief review Examining Types of Causes Understanding Rules of Causation Case Examples Next 30 days 4 Please be certain your phone lines are muted or computer speakers turned down to allow for open discussion on the phones

5. Past 30 Days ACTION ITEMS Continue to send in your scenario examples (for our Spring webinar discussions) Develop your training plan Identify what your staff role and expectations will be regarding your fair and just culture 5

6. Event Investigation Review 6

7. The Basics of Event Investigation What happened?Why did it happen?How were we managing it? 7 Increasing value

8. The Basics of Event Investigation Understanding the link between the outcome and behavioral choices Explain human errors – What performance shaping factors impact these? System Personal Performance Explain at-risk behaviors – Why was the decision made? – How prevalent is the behavior? 8

9. Reviewing Your Existing Processes What happened?What normally happens?What does procedure require?Why did it happen?How were we managing it? 9 Increasing value

10. © 2012 Event Investigation What is the role of event investigation in the management of risk? Single Event: To Explain To Predict To Solve To Allocate Responsibility Systemic Investigation: To inform the organization of dominant risks, causal failure modes, and rates

11. © 2012 Common Traps  Guessing or Assuming  “I’ve seen this before….”  Not doing an investigation  Not talking directly to the people involved  Arriving at a conclusion too early

12. © 2012 Examining Types of Causes

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15. Cause vs. Correlation

16. © 2012 5 Rules of Causation 1.Causal Statements must clearly show the ‘cause and effect’ relationship 2. Negative descriptors may not be used in causal statements 3.Each human error should have a preceding cause 4.Each ‘at-risk’ behavior/violation, or procedural deviation, should have a preceding cause. 5. Failure to act is only causal when there was a pre- existing duty to act.

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24. Case Study Review

25. © 2012 Causal Diagram Process

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27. Case A - Housekeeping Example

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29. Case B – Central Venous Catheter

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32. Group Discussion 32

33. Event Investigation Hands On Practice Example 33 Prior to May 1 webinar Using an in-house scenario, have your JC team walk thru an event investigation process using what you have learned Be prepared to share with the group what insights you discovered as a result.

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35. The Next 30 Days ACTION ITEMS Assess your current event investigation processes Using an in-house scenario, have your JC team walk thru an event investigation process; be prepared to discuss Please send a scenario examples (for our Spring webinar discussions) 35

36. Thank You! Questions? May 1 st Just Culture Webinar 10-11 am Coaching At-Risk Behavior 36