Stephen L. Davidow, MBA-HCM, CPHQ, APR Quality …...• Today’s webinar is being recorded • The...

Root-cause Analysis: Digging Deep to Improve

Stephen L. Davidow, MBA-HCM, CPHQ, APR

Quality Improvement Program Manager

©2015 PCPI Foundation. All rights reserved.

Today’s Speaker


PCPI Quality Improvement Program Manager

Performance Improvement

American Medical Association

Chicago, IL

2


Reminders

• Today’s webinar is being recorded

• The slides and a link to the recording will be posted on

the PCPI QI program website

• Please use the chat for the Q&A

3


Save the dates – New webinars!

October 11 – Leading Practices Series

Success Stories from the Choosing Wisely Campaign

Daniel B. Wolfson, MHSA, Executive Vice President and Chief Operating Officer

ABIM Foundation

November 15 – Skills-building Series

Value-stream mapping: Learning to see opportunities for improvement


PCPI Quality Improvement Program Manager

4


Upcoming PCPI Conference Activities

October 25, Pre-conference all-day QI workshop – 8:30 am to 3:30 pm

Collaboratives: How to ignite the spark and drive improvement in an era of MACRA

October 25, The Leadership Circle: Inaugural Event – 5:30 pm to 8:30 pm

TOPIC: The importance of leadership to drive quality Improvement

Richard Shannon, MD, EVP for Health Affairs, University of Virginia Health System

October 26, Education Session, 3:00 pm to 5:00 pm

Preparing for MIPS, part 2: A Clinical Practice Improvement Activities showcase

5


Agenda

• What is a root cause and root-cause analysis?

– Why is it important?

• What are the three approaches to RCA?

– Cause and Effect diagrams

– 5 whys

– Failure Modes and Effects

• Which approach to use

• RCA use in medical errors: National Patient Safety Foundation’s RCA2

• Take-a-ways

• Questions


What is a root cause?

“A fundamental cause for the problem, error, or defect in a system. Called a root cause because you often have to look beyond the surface of a problem to find it.”

Adapted from: Lean Hospitals, Improving Quality, Patient Safety, and Employee Satisfaction, M. Graban, 2nd Ed., 2012.


Why do errors occur?

• “The majority of medical errors do not result from individual recklessness or the actions of a particular group—this is not a “bad apple” problem. Most commonly, problems are caused by faulty systems, processes and conditions that lead people to make mistakes or fail to prevent them.”

- IOM Report: To Err is Human

• 94% of errors are the result of the system

- W. Edwards Deming


Definitions

• Violations – Intentional acts that go against accepted practices (avoidable)

• Errors – Events that go wrong even if everyone involved had the best intentions and performed properly.

• Lapses – Mental errors, such as forgetting a step

• Slips – Physical errors, such as turning the wrong dial.



Questions

Why did this happen? Different philosophies

• Who is to blame? – Search and destroy mission

• How could this happen despite our best intentions? – Seek understanding, knowledge and wisdom

– Basis for improvement


John Shook: The problem with problem solving

• Assuming you know what the problem is without seeing what is actually happening

• Assuming you know how to fix it without finding out what is causing it

• Assuming the action you have taken to fix a problem is working without checking to see if it is actually doing what you expected

• In other words – “…prematurely jumping to conclusion and solution.”

- S. Davidow


Root-cause analysis: Retrospective

5 Whys

1.Why?

2.Why?

3.Why?

4.Why?

5.Why?

4Ms and 7Ms

• Manpower (People)

• Machine

• Method

• Material

• Money

• Measurement

• Mother Nature (Acts of God/Bad Luck)


About 5 whys and when to use?

• Tool created at Toyota

• It’s a guideline. No magic about 5; sometimes 3, sometimes 6, and may be up to 10

• Focus on getting past the commonplace problem solving going beyond a surface problem and not the root cause

• Works well in a group setting

– Builds off each others contributions

– Gain common understanding

• Needs an open cultural environment; or can help create that environment

• Specific: Why did that specimen arrive at the lab unlabeled?

• General: Why are patients being boarded in the ED?


Lost specimens: Scenario

• On a single day the hospital lab lost three patient specimens.

• As a result, tests and procedures were delayed or repeated, including biopsies for two patients had to be redone.

• Resulted in wasted time and increased pain for the patients.

• Serious reportable, sentinel event.

• Hospital’s quality department’s root-cause analysis concluded that the one histology technologist needed to be retrained.

• Lab director felt the analysis was flawed and started his own analysis by talking to all the histology techs to understand what happened.



Lost specimens: 5 whys analysis

1. Why were the specimens lost?

The one lab technologist was overworked.

2. Why was the one technologist overworked?

Because one technologist was sick and another was stuck in traffic.

3. Why was the one technologist rushing and trying to do the work of three people?

He was trying to hit “the first slides by 8 am” deadline.

4. Why?

Because he was trying to please the pathologist.

5. Why?

Because that is the culture of the hospital.



Lost specimens: Results and Changes

• Problem viewed as a “management system” issue, not the one technologist.

• 8 am deadline viewed as a general goal, not a quota – never cut corners to hit targets.

• Technologists had placed pressure on themselves and acknowledged no pathologist had yelled at any of them.

• Recognition that even with 2 techs, work would need to be done more slowly.

• Emphasis placed on doing a good and accurate job over the deadline.

• Created standard work communication to let pathologists know when there was an unavoidable shortage of technologists.



Central line infections – Allegheny Hospital

1. Establish current condition: Chart review of 1,700 MICU and CCU patients for past year

• 5.1 infections per 1,000 line days

• 37 had contracted central line infections, some more than once

• 19 died (51%)

• Goal: ZERO infections

2. Observe the actual work in detail, over time

• 40 hours of observation

• Noted procedures followed by line placements, line maintenance (e.g., dressing changes), and communication during activities

• Noted that femoral lines took longer to dress than subclavian lines

3. Use real-time data and act on it immediately

• Reverted to using data from the lab

• If infection revealed, team went to bedside within six hours to determine the root cause.

Adapted from the Pittsburgh Way to Efficient Healthcare, N. Gruden, 2008.


Value stream map - Current state

Patient

Family

Physician

Health Care

team

ED:

House

officer

Assess

patient

Insert

femoral line

Infection

develops

Bedside

team

assesses

patient

Remove

femoral line;

insert

subclavian

Administer

antibiotics

6 hours

Supplier

Customers

4 days

after line

insertion Patient

recovers

from infection

Current state

Central line insertion

Allegheny Hospital



Root-cause analysis: Lines inserted into the femoral, or groin, area are more likely to become infected despite campaign to use subclavian or jugular area.

1. Why did the patient have a femoral line?

– The line was inserted emergently at night

2. Why would a physician choose to insert a femoral line at night?

– At a teaching hospital, fellows usually end their shift at 6 pm. House officers must call a fellow in from home or insert themselves.

3. Why would house officers choose a femoral line?

– Because many house officers had not been trained yet to insert the subclavian lines, and femoral lines were safer and easier to insert until they were trained.

4. Why would a femoral line be left in for four days?

– Because the risk of infection had been understated, there was no sense of urgency to remove and insert a new line in a preferred place.




4. Address problems, one by one, as close to the time and place of the occurrence as possible.

As a result of the root-cause analysis, staff members created standard work (countermeasures):

– Remove femoral lines within 12 hours and replace with a line at a preferred site.

– Replace dysfunctional catheters; do not rewire them.

– Replace lines present on transfer.

– Prefer the subclavian position for central lines

• Training module developed, including use of simulator

• All new clinicians trained

• Paid for using money saved by having fewer central-line infections

Results: 1,898 lines inserted, 3 infections, ZERO deaths.

>95% reduction in central-line infections in the MICU and CCU


Why do clinicians not follow hand hygiene practices 100% of the time?

Emergency situation They think alcohol gel

cracks their hands

Soap and water takes oil out of hands making

skin crack

The alcohol makes those cracks sting

They are using a mix of soap and water and gel

instead of just gel

Lack of training

Lack of awareness on practices and requirements

Lack of training

Lack of resources

Lack of administration attention

Too many pressing issues

They forget because they are in a hurry

RN is often running in response to MD

request

Culture of “jump when MD says jump”

Gel dispensers are not convenient

Gel dispensers are not on the computer carts

Their hands are full when leaving a room

Too hard to find carts, so RN and techs carry

things in their arms

Carts are not always stored in the same

place

Lack of 5S organization

Not enough carts in the unit

Been told to keep hallways clear

Not enough storage space nearby

5 Whys Example:

Multiple Causes



About fish-bone diagrams and when to use?

• Tool created at Toyota

• AKA, Ishikawa diagram

• When there are multiple contributing causes

• For more complex problems that may need statistical analysis to understand the error or the failure


Root-cause analysis: Retrospective

5 Whys

1.Why?

2.Why?

3.Why?

4.Why?

5.Why?

4Ms and 7Ms

• Manpower (People)

• Machine

• Method

• Material

• Money

• Measurement

• Mother Nature (Acts of God/Bad Luck)


Ishikawa (AKA: Fishbone or cause-and-effect) diagram

Primary cause

Secondary

cause


Current value stream map


TIM P WOOD – Identifying


Gap analysis – Fishbone diagram


Side-by-side analysis


5 why - deeper understanding of the gaps


Failure Modes and Effects Analysis (FMEA)

• Used prospectively when a process, product or service is being designed or redesigned, after quality function deployment.

• When an existing process, product or service is being applied in a new way.

• Before developing control plans for a new or modified process.

• When improvement goals are planned for an existing process, product or service.

• When analyzing failures of an existing process, product or service.

• Periodically throughout the life of the process, product or service.


How’s it work?

• Brainstorm all potential failures in advance

• Design systems to address the identified potential failure modes

• Develop standard work to counter act or serve as counter measures (prevention)

– Create checklists

– Modify systems and work stations as necessary

• Usually done as a spreadsheet

• Based on team brainstorming

– Engages team members involved in the process


How do you prioritize?

For each failure mode, team ranks each on three categories:

• What is the severity of the error when it occurs?

• What is the likelihood of occurrence?

• How difficult is it to detect the error?

Score each failure

1. Score on scale of 1-10 (low to high)

2. Multiply scores together for a risk number (RPN)

3. Assuming not all risks can be addressed, so prioritize by RPN

If, error is likely (score 10), hard to detect (score 10), and cause patient death (10) – RPN of 1,000 vs. not likely (2), not hard to detect (score 2), and not likely to cause injury (score 2) – RPN of 8


Sample FMEA Prioritization Grid

Function Potential

Failure

Mode

Potential

Effects(s)

of Failure

Severity

Score

(S)

Potential

Causes(s)

of Failure

Occurrence

Score

(O)

Current

Process

Controls

Detection

Score

(D)

RPN Responsibility

and Target

Completion

Date

Action Results:

Action taken

Perform

biopsy -

Take

specimens

Misidentify

specimen

Adapted from the American Society of Quality website.


Which RCA approach to use?

It depends!

• 5 whys

– Great way to get started

– Engages teams in understanding and defining the root cause(s) together

– Serves as the basis for generating ideas for improvement

• Fish-bone diagramming

– Useful when there are multiple contributing factors

– For more complex problems that may require statistical analysis – provides a starting point

• Failure Modes and Effects Analysis

– Design systems to address the identified potential failure modes

– Develop standard work to counter act or serve as counter measures (prevention)

– Helps prioritize what to work on first


RCA2: Improving Root Cause Analyses and Actions to Prevent Harm

National Patient Safety Foundation Initiative:

• Root Cause Analysis + ACTION

• Standardize process

• Risk-based rather than severity-based

• System-based approach (human factors engineering)

• Goal is action and real improvement

• Sustainable results

• Starts with defining blameworthy events


RCA2: Elements

• Risk-based – severity vs. likelihood (Probability)

• Non-punitive

• Timing & team membership

• Determination of:

– What happened?

– Why it happened?

– What actions to prevent future re-occurrence?

• Formulation and implementation of stronger actions

• Follow up – Measurement

• Sustainment


RCA2: Timing

• Have an established team in place to quickly respond – be prepared

• Patient is top priority

– Medical care and treatment

– Disclosure to patient and family

• Make environment safe

• Preserve evidence

– Sequester medical equipment and other material

– Find out what occurred


RCA2: Role of patient/family

• Patient representative recommended

• Involved patient/family has role but not on the team

• Consider:

– Ability and willingness to participate

– Psychological and legal barriers


RCA2: Interviewing

• Prepare well

• Use experienced interviewers not involved in event

• Use listening skills

• Focus on “Just the Facts”

• Care takers and patients/family members should not be part of team deliberations

– May relive event and cause additional stress


RCA2: Summary

• Active leadership participation – CEO and board support

• Blameworthy definition

• Transparent risk-based prioritization

• Timeliness

• Team composition

• Tools: Triggering questions, five rules of causation, action hierarchy, etc.

• Feedback

For more information: npsf.org/RCA2


Take-a-ways

• Learn what the cause of the problem is, rather than assume or judge incorrectly

– “We’ll give him a fair trial, and then we’ll hang him.”

• Serve as basis for real improvement instead of prematurely jumping to “solutions”

• Can use RCA respectively to understand and prospectively to avoid errors or breakdowns

• Sensitivity in the use of RCA for operational issues vs. patient harm/safety events


Thank you!


Q&A

Please ask questions via the chat box now.


[email protected]

312-464-4346

mailto:[email protected]




Stephen L. Davidow, MBA-HCM, CPHQ, APR Quality …...• Today’s webinar is being recorded • The...

Documents

Transcript of Stephen L. Davidow, MBA-HCM, CPHQ, APR Quality …...• Today’s webinar is being recorded • The...