The Mihalik Blog

Root Cause Analysis

Requests from hospitals for assistance in facilitating root cause analyses of sentinel events are up this year.  This appears to be related to the Joint Commission’s more intensive focus on this area.

Although the process for completing a root cause analysis remains rather opaque in most instances, the final products are remarkably similar.  They usually bear a strong resemblance to the framework promulgated by the Joint Commission or to a conceptually similar format required by regulation. 

If a particular format is not required by regulation, I think some modifications of the Joint Commission’s suggested form can make the document much more user-friendly. 

Those of you who know me know that I’m usually more inclined to use a concise narrative style rather than a series of checkboxes when trying to describe something.  So, the Joint Commission’s boxes for “Root Cause?”, “Ask ‘Why?’”, and “Take Action?” don’t do much for me.  I’d rather analyze each issue until the root causes are identified at which point they can be simply listed as a bulleted list at the end of the narrative that concisely sums up the analysis of that specific issue.  Doing this eliminates the need for the first two boxes since the group continues to “Ask Why” until they’ve reached a “Root Cause.”  A major benefit of this is that each topic can be fully developed in a single place on the report rather than scattered around a lengthy form like installments in a Victorian novel. 

When the analysis is complete, each root cause can be copied into a table where planned interventions and measures of effectiveness can be listed, along with other critical information like responsible person and due dates.  If a root cause is not going to be acted upon, the same table can be used to explain why.  The third check box is now gone.  In its place is a clear description of the interventions for each root cause or the reasons for not intervening. 

I think these modifications of the reporting template (along with a few others) make the results—and the reasons for the results—much more understandable.  Of even more significance, though, is the process that I recommend to develop an understanding of the event. 

Knowing that in the end I’ll need to correlate the results with the minimum required scope of a root cause analysis, based on the type of event, I simply forget about the need to do this throughout the bulk of the analysis.  I believe that trying to make a group think in narrowly defined categories hinders, rather than helps, analysis.  With a good facilitator, the group can conduct a thorough analysis using a few standard tools and techniques of quality improvement, such as brainstorming, nominal group technique, and a prioritization matrix.  Afterwards, each of the root causes can be associated with one or more components of the required scope such as staffing levels or supervision of staff.  With good facilitation you’ll likely find that you’ve touched on all the required processes or else decided that a particular process was not relevant. 

A solidly conducted root cause analysis can be an effective component of an organization’s quality improvement strategy.  If you’re facing one of these events and want some assistance we’re here to help.

Joint Commission Update Part III

This is the final installment of Michael Alcenius’ Joint Commission Update.  I’ll be back next week. 

Gary

I walked away with from the Joint Commission Hospital Executive Briefings in

Garden Grove, California with an appreciation of the significant restructuring of the emergency management standards in the Environment of Care chapter.  Most of the modifications are based on lessons learned from disasters that have impacted health care since 2001 (e.g., 9/11; Katrina).  The new standards, effective January 1, 2008, emphasize a scalable approach to managing response and organizational self-sustainability for at least 96 hours.

As a foundation, it is important to understand three definitions relative to events that impact an organization’s ability to provide care:

·        Emergency

o       Infrastructure remains intact

o       Able to support care/services

o       No deaths directly related to the event

·        Disaster

o       Infrastructure damaged

o       Able to support care/services

o       Few deaths directly related to the event

·        Catastrophe

o       Infrastructure damaged

o       Not able to support care/services

o       Many deaths possible

In addition, the new structure addresses six important areas of emergency management

·        Communication

·        Resources and assets

·        Safety and Security

·        Staff roles and responsibilities

·        Utility management

·        Clinical and support activities

A synopsis of the revised standards follows.   

EC.4.11 Planning

·        Hazard Vulnerability Analysis (HVA)

·        For each emergency identified in HVA, define:

o       Mitigation activities

o       Preparedness activities

o       Response strategies

o       Recovery strategies

·        Document assets and resources needed during emergencies

·        Objectives, scope, performance, effectiveness of planning is evaluated at least annually

EC.4.12 Written Plan

·        Emergency Operations Plan (EOP)

o       Establishes incident command structure

o       Identifies staff reporting structure

o       Identifies organizational capabilities

o       Establishes response efforts when organization cannot be supported by community for at least 96 hours

o       Identifies alternate sites of care for evacuation if necessary

EC.4.13 Communications

·        Plan for ongoing communication

·        Communication with other organizations in area

·        Communications with patients and third parties such as FBI, Health Department

EC.4.14 Strategies for Managing Resources/Assets

·        Plan for obtaining supplies at onset of emergency

·        Plan for replenishing

·        Managing staff resources

·        Managing staff and family support needs

·        Sharing of resources with other organizations

·        Evacuation

·        Transporting patient and resources during evacuation

·        Transporting patient information

EC.4.15 Strategies for Managing Safety and Security

·        Controlling egress and exit

·        Controlling movement within facility

·        Controlling traffic

EC.4.16 Staff Roles and Responsibilities

·        Define roles

·        Train staff for roles

·        Communication to LIPs about role

·        Identification of care providers and other personnel

EC.4.17 Managing Utilities

·        Identify alternative means for providing

o       Electricity

o       Water

o       Fuel

o       Ventilation/Heat

o       Medical gas/vacuum

EC.4.18 Managing Clinical and Support Activities

·        Personal hygiene and sanitation

·        Mental health

·        Mortuary services

·        Documenting and tracking clinical information

EC.4.20 Exercising the Plan

·        Define scope of exercises

o       Number and types – twice annually in response to actual emergency or planned exercise, one must include influx of actual or simulated patients

o       At least one escalated to evaluate performance when community cannot support

o       At least one community-wide exercise/year if organization has a role in community structure

o       Realistic addressing emergencies identified in HVA

o       Monitor performance and identify opportunities for improvement

o       Monitor the six crucial areas

§         Communication

§         Resources

§         Safety and Security

§         Staff roles and responsibilities

§         Utility systems

§         Clinical and support activities

·        Critique

o       Multidisciplinary process

o     EOP modified in response

Joint Commission Update Part II

My previous blog entry outlined highlights relating to administrative updates at Joint Commission gleaned during my recent attendance at the annual Executive Briefings.  This entry will address some of the modifications and additions to National Patient Safety Goals and standards for 2008.  Next time I'll convey significant changes to the structure and standards found in the Environment of Care chapter of the Accreditation Manual for Hospitals.  Feel free to ask questions and I'll be happy to offer insight. 

National Patient Safety Goals 2008 for Hospitals

·        1A – 2 patient identifiers

·        1B – Time out prior to surgery

·        2A – Read back for verbal orders

·        2B – Prohibited abbreviations (list hasn’t changed)

·        2C – Measuring and improving time of reporting critical test results

·        2E – Standardized approach to hand off communication

·        3C – List of look alike, sound alike medications (list is at www.jointcommission.org)

·        3D – Labeling of medication containers on and off sterile field

·        3E – NEW – Reduce likelihood of harm associated with the use of anticoagulation therapy

o       Define the program

o       Unit dose and pre-mixed parenterals

o       Dispense Warfarin based on established monitoring procedures

o       Use protocols

o       Baseline and current INR monitoring for Warfarin

o       Notify dietary

o       Use programmable infusion pumps for continuous IV Heparin

o       Policy for  baseline and ongoing testing for management of Heparin therapy

o       Anticoagulant education to staff and patients

o       Evaluate anticoagulant safety practices

·        7A – Hand Hygiene

·        7B – Manage death or permanent loss of function associated with health care-associated infection as a sentinel event

·        8A – Medication Reconciliation

·        8B – Communicate the list to the next provider of care and to the patient upon discharge

·        9B – Implement fall reduction program and evaluate effectiveness

·        13A – Define and communicate means for patients to report concerns about patient safety

·        15A – Identify patients at risk for suicide

·        16A – NEW – Select a method for staff to directly request additional assistance from a specially trained individual(s) when patient’s condition appears to worsen – Rapid Response Team

o       Select method

o       Develop criteria

o       Empower staff, patients, families

o       Educate requesters and responders

o       Measure utility and effectiveness

o       Measure arrest and mortality rates

Phase in milestones for new goals (3E and 16A)

·        3 months – assign responsibility

·        6 months – work plan in place

·        9 months – pilot testing underway

·        12 months – fully implemented

Universal Protocol

·        1 – Pre-op verification process

·        2 – Site marking

·        3 – Time out immediately before procedure (NPSG 1B)

Standards Changes for 2008

·        Accreditation Participation Requirement 17 (APR 17)

o       Changes to verbiage makes it clear that medical staff and employees must be educated about reporting concerns relating to safety or quality of care to Joint Commission without retaliation.

·        LD.3.110  Asystolic Recovery/Organ Procurement

o       Hospital must document efforts to reach an agreement with OPO

o       Donation policy reflects justification for not providing asystolic recovery

·        LD.3.50  Oversight of Contracted Services

o       Assure same level of care delivered regardless of relationship

o       Requires monitoring for safety and quality

o       Credentialing and privileging

·        PC.2.10 Timeframes for Histories and Physicals

o       Organization defines in writing timeframes for conducting initial assessments

o       H&P completed no more than 30 days prior or within 24 hours after inpatient admission

o       H&P completed within 30 days prior to inpatient admission must have an update stating any changes in patient’s condition within 24 hours after inpatient admission or prior to surgery

o       These changes bring the standard in line with CMS Final Rule effective 1/27/07

Next Installment:  The new Emergency Management Standards for 2007!

Michael Alcenius, CPHQ

Director - Quality and Risk Management

Lovelace Westside Hospital

Albuquerque, New Mexico

Joint Commission Update

I’m taking a brief hiatus from blogging while Michael Alcenius fills you in on some changes with Joint Commission standards.  I’ve known Michael for many years—since he and I both worked at the Joint Commission in the Department of Standards in the early 1990’s.  Michael held a number of positions with the Joint Commission over the years but now, he’s in the private sector applying his standards knowledge in another way.  Without further delay, here’s Michael…

I attended the recent JCAHO Executive Briefings in Garden Grove, CA and walked away with a fairly thorough understanding of what to expect in the years to come.  The standards-based agenda addressed upcoming changes for 2008 and also touched on real and potential updates for 2009.  In addition, faculty touched on changes in the Joint Commission Leadership, survey process, and Manual organization.  In a nutshell, here we go….

·        The corporate name “Joint Commission on Accreditation of Healthcare Organizations” has been shortened to “The Joint Commission.”

·        JAYCO (the JCAHO extranet site) has been renamed - The Joint Commission Connect.

·        Dr. Mark Chassin, MD is replacing the retiring (retiring from his position, not referring to his personality) Dr. O’Leary as president in 2008.

·        A standards improvement initiative is once again “reorganizing, clarifying, and refining” standards and “simplifying” scoring.

·        Strategic Surveillance System (S3) – A performance based risk assessment will be accessible on the secure extranet site as of mid year.  Though not required, it is a good tool for focusing improvement efforts.  Surveyors do not have access to the tool.  There is no additional cost and it does not impact your accreditation decision in any way.

·        The automated sentinel event reporting system available January 2007 is now mandatory.

·        A Life Safety Code Specialist surveyor will be added to all hospital surveys in 2008 for one day unless square footage is over 750,000 – in that situation, 2 days.

·        Currently, an unannounced survey can occur anytime within the year that it is due.  In the future it will occur 18 to 39 months after the previous full survey.  Labs will have a 12 to 24 month window.  Poorer performing organizations will be surveyed earlier.

·        I suggest you develop a “ready to go” binder or box.  Designate backups for leadership if not available.

·        Also, make sure you verify the identity of your surveyors on your extranet site when they show up.

Next time I’ll get to the standards-based issues, so stay tuned.

Michael Alcenius, CPHQ

Director - Quality and Risk Management

Lovelace Westside Hospital

Albuquerque, NM