Critical Event Review (Root Cause Analysis) Hutchinson Area Health Care December 2008.
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Transcript of Critical Event Review (Root Cause Analysis) Hutchinson Area Health Care December 2008.
Critical Event Review(Root Cause Analysis)
Hutchinson Area
Health Care
December 2008
What are we going to cover?
• What is Critical Event Review (CER)? – Brief Overview
• Reasons for conducting a Critical Event Review
• Hutchinson Area Health Care’s use inLong Term Care - Process
• Story
What is a Critical Event Review?
• A process that uses a systems approach for identifying the basic causes for an undesirable event or problem
• Focus on the process and systems, not individuals
• Uses the technique of asking the “why” question multiple times
• A confidential process
Reasons to do a Critical Event Review
• It is a review process used to uncover the facts and the underlying story that led up to the event– Identification of contributing factors– More in-depth understanding of the sequence of events
• Assists in improving facility systems/processes
• Promotes proactive Action Plan development to assist in preventing recurrence
• Resident Safety– Reduce the harm to residents by increasing the
resilience of our responses when the event repeats
Events where use of CER could be considered…
• Events with serious outcome for the resident
• Repeating incidents
• Near Misses/Good Catches
• Examples: – Falls
– Medication Errors
– Plan of Care not followed
CER Selection Criteria
• Initially Joint Commission driven – Sentinel event standard requiring RCA’s to be done
• Was applied to CMS sentinel event criteria• Based on event data analysis
– Highest event (falls)
– Severity
• Resident safety focus – reduction of harm • Future – working to be proactive – near miss
Immediate Actions• Ensure resident and staff are safe
• Notification of Administration
• Assess need for additional resources
• Secure equipment, tubing, medications, involved in event
• Communication to resident and family
Immediate Actions (continued)
• Complete documentation by the care provider– Medical Record: Facts- Objective data/description of
event– Event/Incident Report
• Institute an immediate corrective action if possible
• Staff Notes (not part of the medical record)– Coach staff: record when resident last seen, what they heard, room
arrangement, location of equipment, your response – Who, What, When, Where, Why– Staff notes need to turned into
Quality Department or Quality Manager
• Drawings/Pictures
CER Meeting Steps
• Set up initial meeting 48 to 72 hours post event (if not sooner)– Who sets up the meeting
• Identify and invite key players• Won’t compromise resident safety
Key Players• Staff from departments/units directly and
indirectly involved in the event
• Nursing Administration
• Medical Director– Physician/Provider as needed
• Quality Representative
• Administrator
• Facilitator
• Others as identified
CER Meeting Steps (continued)
• Coaching Staff – May be initiated prior to meeting being set up
if member has not participated before• Participation in the CER is an opportunity to learn
• Chance for staff to tell their story
• Emphasis is on improving the system
• Just in Time Training
Meeting Preparation
• Room with comfortable atmosphere
• Flip Chart and Markers
• Kleenex
• Coffee/Water/Treats
• Medical Record/Reports
• Any of the pre-work documentation– Staff Notes– Chart Review
• Lead nursing completes
– Time line of the event
Facilitator • Team training/group skills
– Clinical background can be helpful, but not required– Listening skills – use facilitation to uncover the story
behind the event– Analytical skills – conversational/timeline versus
investigation data gathering
• Positive – sense of humor – sensitive – deal with emotions – awareness
• Strong boundaries– Brings people back to focus– Ability to manage emotion at the table – fear/anger– Is able to identify and draw out people– Engages the entire team to give their perspective
• Need to support everyone’s style
Recorder
• Recorder – listen to how they are saying, as well as what they are saying– Facilitator may be the recorder as well– Would recommend a recorder be available
Meeting Format
• Introductions and Ground Rules – Confidentiality– Titles left at the door - all members need to be
active participants– There are no bad questions– Systems and process focus
• Not blaming/finger pointing
– Want to foster creativity • “You” have the solutions
• Brief orientation to CER
CER Meeting in Progress• Tell the story• Brief overview of resident• Start with the person who found resident
• Try to obtain details of what happened
• What did you see?
• Encourage people to share • Facilitator stands in front and captures data on white flip chart
– “BIN” list – gives credence, but allows facilitator to move back to subject
• Try to identify opportunities /gaps as the story is presented
• Why, Why, Why?– How were they laying? Where was the wheel chair?
– What is the purpose having the wheel chair across the room?
Use of Triage Questions
• Helps team understand event• Assures thoroughness of investigation –
“buckets”– Human factors
• Staffing– Communication/Information– Equipment/Environment– Uncontrollable external factors– Training– Rules/Policies/Procedures– Barriers
Forms
CER Meeting cont.
• Identification of factors that may have influenced the circumstances that led to the event– Identification of system/process gaps– Opportunities identified for improvement
• Feedback from participants on how systems can be improved is critical– Is there anything that we could have been done differently?
• Development of an action plan – based on findings – with target dates and responsible party listed– Monitoring/measurement plan as indicated– (Critical Event Review Corrective Action Plan -to be covered more in depth in later
presentation)
• Follow-up
Spread the Success/knowledge
• Share with staff and Administration– Need to go beyond interdisciplinary care team
• Potential: – Share learnings and collaborate with other
facilities
Critical Event Review Summary
• To be thorough, a RCA must include:
– Determination of human and other factors– Determine related processes and systems– Analysis of underlying causes and effects –
series of why’s– Identification of risks and their potential
contributions
Questions?
Thank you!