FMEA: A new QI tool to help improve case management processes
Failure mode analysis can be used to improve virtually any CM activity
Case managers are no strangers to quality improvement (QI) tools; for many years they have used a number of QI tools to improve processes and to help them meet accreditation standards.
But the Joint Commission on Accreditation of Healthcare Organization’s (JCAHO) current patient safety standards have created the opportunity — some would say the need — to introduce an entirely new QI tool to case management professionals: failure mode and effect analysis, or FMEA.
"FMEA is a proactive tool," explains Patrice L. Spath, a consultant with Brown-Spath & Associates in Forest Grove, OR. "It does not start with an assumed or identified effect and work backward, like a cause-and-effect diagram does. You simply take a process and use the FMEA technique to improve it."
"With other QI tools, you first identify the issues," adds Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting in Metamora, MI.
"With an FMEA, you thoroughly analyze the process, which would be particularly helpful in solving these types of problems," she explains.
The concept of using QI tools to improve case management processes makes good sense, Homa-Lowry continues. "JCAHO standards encourage the use of statistical process improvement tools, and since case management is a process, it makes sense to use these tools to evaluate how to improve case management."
What is FMEA?
It is perhaps the basic approach of FMEA that sets it apart from other QI tools, Spath says. "A lot of QI tools say, Here’s a bad thing; now let’s work back and find out what caused it.’ But your goal in FMEA is to prevent things from going wrong, or to reduce the undesirable impact when they do go wrong," she adds.
While JCAHO standards do not mandate a specific risk-analysis model, accredited organizations are expected to use a systematic and analytic technique to identify and address failure modes in high-risk patient care processes, Spath notes.
The FMEA process, she explains, covers five basic steps:
- Choose the process to be studied.
- Assemble a multidisciplinary team.
- Organize information about the process under study.
- Conduct hazard analysis.
- Develop and implement actions and outcome measures.
Let’s say your hospital has chosen to do an FMEA on the patient admission process. Once you have identified four to seven individuals with personal knowledge of this process to form your team, you can meet to organize your information and discuss the goals and scope of the project. A flowchart of the admission process is created. Next, the team conducts a hazard analysis that includes the following steps:
- Identify failure modes for each process step.
- Determine the potential effect of each failure mode.
- Rank the severity of the failure mode effect.
- Rank the probability and detectability of each failure mode.
- Identify the areas of greatest concern (the critical failure modes).
The tables, below illustrate several key components of the FMEA methodology. The "Possible Effects of Potential Failures" chart depicts the first and second steps of the hazard analysis. In the first column, the process steps are listed. (Only two steps are shown in this example.)
Potential failures, or things that could go wrong at the process step, are listed in column two. In the last column, the possible effects are listed, these are undesirable things that might happen if the failure actually occurs.
The other tables illustrate severity scores and probability and detectability rating scales. The team uses these to rate the potential failures and effects to identify the significant or critical failures from occurring.
One of the most intriguing aspects of FMEA is its versatility. It easily can be used as a stand-alone tool, but it also can be used in concert with more familiar tools such as Pareto charts and cause-and-effect "fishbone" diagrams.
"If you want to focus on high-risk areas [hospitals are required by JCAHO to improve a clinical process at least once a year that is high risk for errors and causing patient harm], to me, the first phase could be to use statistical process tools to begin to look at the data concerning case management activities," says Homa-Lowry. "What the Joint Commission is saying in its performance improvement standards is that you should use baseline data first of all, to see whether you truly have an issue."
"We’ve learned over the years that different QI tools can be used for different purposes," Spath adds. "FMEA can help you identify all the possible things that can go wrong so you can strengthen the process to minimize the chances of anything going wrong. The first step is identifying a process you want to improve. Other QI tools can be used to identify the process you want to do an FMEA on."
For example, she notes, a Pareto chart can be used to identify the few vital areas that cause some of the biggest problems.
A Pareto chart basically is a bar chart. It might be used, for example, to display the causes of discharge delay. "The highest problem area might be untimely case management referrals after patient admission," Spath says.
You would then ask yourself what process is most intimately involved with case management referrals. "Most likely, it would be the admission process," says Spath. "An FMEA project then could be used to identify what can go wrong, so the process can be redesigned to prevent significant process breakdowns in the future."
"The first step is to get comparative data about your performance, using tools such as Pareto analysis, to begin to identify why the current process is not working," says Homa-Lowry. "Then you can use FMEA to learn where to modify the processes, to prevent things from going wrong."
A Pareto also might be used to look at delays in discharge planning, and the biggest reasons for those delays, says Homa-Lowry.
"It could be placement, delays in procedure completions, or perhaps discharge planning was not started soon enough," she notes. "You can use Pareto to prioritize why they happened — was it a case where planning was not started soon enough? Was it the workload of case managers? Pareto is used more for the display of data and to put you in the position of implementing process change more effectively."
Fishbone diagrams, on the other hand, are used when you already know what the undesirable effect is, Spath explains. "It might be missing patient demographic information from hospital face sheets," she says. "If that’s identified as the biggest problem area, you would then brainstorm all the possible causes using the diagram for visual assistance."
It’s important to remember that when you’re considering using FMEA as a process improvement tool, you should have a broad vision. "It’s true that FMEA can be very useful in meeting JCAHO’s patient safety standards, but it can be used to improve any process — not just clinical processes," Spath asserts.
Case managers also can use FMEA to help meet JCAHO’s continuum of care standards, Homa-Lowry says. "It’s a natural fit, because they are asking you to evaluate the whole continuum of care process," she says. "You can look at how people enter the organization, what happens if they’re transferred somewhere else, and so forth. These are all processes to make sure the patient is going through each setting in an optimal way."
Organizations can and should use data they have available about their organization to identify and prioritize improvement efforts, Homa-Lowry notes.
"They can use the information in the functional [JCAHO] chapters to evaluate some of their patient care processes," she suggests. "For example, in the continuum of care chapter, the discharge planning process could be examined in relation to a specific DRG if it is determined that the discharge planning process is one of the reasons that the organization is not performing as well as another organization for this DRG."
And don’t forget, Homa-Lowry says, once you have implemented your new or redesigned processes, you must evaluate the effectiveness of your actions. "The Joint Commission says that once you initiate a change, you must go back and see if it works," she notes, pointing out that statistical process control charts can be used "on the back end" to make such a determination. "With its emphasis on patient safety, the Joint Commission is really taking a hard look at quality of patient care and improving outcomes."
[For more information, contact:
- Patrice L. Spath, Brown-Spath & Associates, P.O. Box 721, Forest Grove, OR 97116. Telephone: (503) 357-9185. E-mail: [email protected]. Web site: www.brownspath.com.
- Judy Homa-Lowry, RN, MS, CPHQ, President, Homa-Lowry Healthcare Consulting, 560 W. Sutton, Metamora, MI 48455. Telephone: (810) 245-1535. E-mail: [email protected].]
Severity Score:
1 = No impact on continuity of care
2 = Minimal impact on continuity
3 = Moderate, short-term impact on continuity
4 = Significant, long-term impact on continuity
Case managers are no strangers to quality improvement (QI) tools; for many years they have used a number of QI tools to improve processes and to help them meet accreditation standards.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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