Here are guidelines for conducting analysis
Perhaps you've decided to jazz up your incident report and quality improvement process to turn them into a root-cause analysis procedure that would meet with approval by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.
That may be easier said than done. But home care quality managers might benefit from following guidelines devised by a health system that has been conducting such analyses for years.
Alliant Health System in Louisville, KY, has made investigation and management of adverse occurrences a priority.
"We've always gone through appropriate committee review and documented findings and investigations," says Nancy Rapp, RN, risk manager for the multispecialty health system, which has a home health agency.
Although the Joint Commission has given a new name and some new twists to the process, it's not a new concept.
"To risk managers, historically there's nothing new to it," Rapp says.
Here is the basic structure of Alliant Health System's root-cause analysis process:
1. Create a process flowchart.
Alliant Health System often uses three flowcharts that seek answers to these questions:
· What happened in this specific event and what was the outcome?
· What should have happened? What does the policy state, and what were we supposed to do?
· What changes have been implemented, and what have we done to reduce the risk for that happening again?
"This is easy to do, and it's basic quality improvement," Rapp says.
Also, the health system follows this process for identifying risks, not just for those occurrences that are catastrophic or sentinel events, Rapp says.
"Actual and averted incidents should be evaluated," she explains. "You need to look at trends and patterns of occurrences."
An example might be medication errors in which there were no injuries. "Are there patterns by unit, by shift, or by certain drugs?" Rapp says.
The Joint Commission's own root-cause analysis flowchart includes these questions:
· What happened?
· Why did it happen; what processes were involved, and what was the cause?
· What are possible solutions, and what steps once taken should reasonably be expected to reduce the likelihood of a recurrence of the event?
· How will you measure the success of the risk-reduction strategies?
· How will you collect and analyze data to substantiate that the desired improvements have occurred?
2. Notify key personnel of the incident.
When a sentinel event occurs at Alliant Health System, Rapp and other managers are notified by a telephone call or a pager. The incident is investigated as quickly as possible.
"There's a chain of notification within the facility of people who need to know what happened because we don't want our administrator or public relations person to hear about it on the 10 o'clock news," Rapp explains.
Then other personnel who might be peripherally involved with the incident need to be notified. For example, the biomedical engineering staff might need to be involved if the event is related to equipment, Rapp says.
Pastoral care also may need to be included, as well as the medical staff director.
"We usually determine when it's reported to us, who has been notified, when they were called, and what we need to do right away," Rapp says. "If it happens at 2 a.m., can we wait until morning?"
3. Investigate the incident.
The investigation begins with talking to whoever is directly involved in the incident, Rapp says.
A key person, such a risk manager - or in a home care setting, a clinical director or quality assurance manager - needs to analyze the event, Rapp says.
The next step is to call a meeting of key staff and involved personnel.
"Often legal counsel will be brought in to assist us with taking statements from people who are directly involved because that helps to protect the statements with attorney-client privilege," Rapp says.
4. Gather information.
Start gathering information in a nonjudgmental way, Rapp advises.
"The key is to try to do this in a fashion that is not considered punitive," Rapp says. "Employees may be upset about the incident and may feel bad for what happened. So we try to reassure them that the process may have failed, but they did not. We really need their support and comments on what we can do to improve the process."
An investigator can do this by interviewing employees directly involved in the incident in a way that does not attribute blame or finger-point. Rapp offers these examples:
· What process improvements do you suggest?
· If something could have been in place to reduce the risk of this happening, what would that be?
· Was it poor lighting, lack of education, equipment problems, or a human factor?
"We don't want any individual to think we're on a fault-finding mission," Rapp says.
Involved employees may feel stress
After involved employees are interviewed, it might be helpful to refer them to an employee assistance program or to have a social worker or counselor speak with them, especially if there has been a serious patient injury or death.
"Try to assist employees up front to reduce the stress they may feel," Rapp advises. "Being involved in a serious occurrence may affect the personal and professional lives of health care providers."
5. Follow the flowchart and make necessary changes.
If the investigation shows that the problem could have been prevented by a policy change, then the organization should make that change.
But the action doesn't end there. The next step is to educate the staff about the change and then monitor compliance.
Here's where quality managers can follow the process they already use in initiating quality improvement, Rapp suggests. "Develop quality indicators, watch it for several months, and then see if we're doing what we said we were going to do. If we are not, then we go back and educate again."
6. Encourage staff buy-in to risk management.
"You need a leadership commitment that risk identification and risk management is a team effort, and you're trying to make things work better," Rapp states.
"We need to help employees understand that our goal is to promote patient safety," Rapp says. "There are so many things we can do proactively to reduce risks before a problem erupts."
Encourage staff to think of suggestions to improve safety, Rapp advises. Set up a suggestion box and then offer incentives, such as a free lunch or accolades in an employee newsletter, if they contribute a suggestion that is implemented by the safety committee.
Alliant Health System gives employees "quality coins" for jobs well done or good safety suggestions, Rapp says.
"Whether it's a housekeeper who takes an extra step to do a good job, or it's an office employee who picks up a piece of trash in a hallway, it shows the person has pride in the organization and is trying to do good," Rapp says.
"It's an ongoing effort to improve quality," Rapp says. "After years of looking at bad apples, health care professionals have started to look at process improvements to promote optimal changes. We don't want to point fingers when something goes wrong. Bad things happen to good facilities. But there should be an ongoing effort to improve processes."
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