Just CultureApplication – Event Investigation

Part 2“Rules of Causation”

Stephanie SobczakQuality Improvement Manager

WHA

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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 @ NoonCall: 1-800-747-5150

Code: 29766

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Just Culture Teams

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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)

Today’s CallApplication – Event Investigation – Part 2• Event Investigation – brief review• Examining Types of Causes• Understanding Rules of Causation• Case Examples• Next 30 days

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Please be certain your phone lines are muted or computer speakers turned down to allow for open discussion on the phones

Past 30 DaysACTION 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

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Event Investigation Review

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The Basics of Event Investigation

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Increasing value

The Basics of Event InvestigationUnderstanding 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?

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Reviewing Your Existing Processes

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Increasing value

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Event InvestigationWhat 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

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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

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Examining Types of Causes

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Cause vs. Correlation

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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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Case Study Review

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Causal Diagram Process

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Case A - Housekeeping Example

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Case B – Central Venous Catheter

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Group Discussion

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Event Investigation Hands On Practice Example

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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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The Next 30 DaysACTION 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 discussPlease send a scenario examples (for our Spring webinar discussions)

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Thank You!Questions?

May 1st Just Culture Webinar10-11 am

Coaching At-Risk Behavior

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