Joint commission root cause analysis case study

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Joint commission root cause analysis case study essay assignment

JC Tool to Assist Organizations in the Completion of the
Framework for Conducting a Root Cause Analysis (edited)

 

Please note that the root cause analysis and action plan must show evidence of an analysis within the key components as outlined on the root cause analysis matrix for the specific type of event.  An area on the matrix that may not have an identified process breakdown should still be summarized to determine that the component was evaluated.

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·         Brief description of event

Briefly summarize the circumstances surrounding the occurrence including the patient outcome (eg, death, loss of function).

 

Example:  A thirty-six year old male admitted for left hernia repair on May 3, 2002.  A right hernia incision was made when the surgeon realized the left side was to be performed.  The right side was closed and the left hernia repair was completed.

·         What area/service was impacted?

Include the full variety of services impacted by the event.

Example:  This might include Operating Room, Nursing, Medical Staff, Recovery Room, and Preadmission Testing.

• What are the steps in the process, as designed?

List the key steps involved in the specific processes relating to the event.

      Example: For wrong site surgery you may list specific steps within key processes such as       Preadmission Assessment and Verification of Site, Site Verification and Assessment by Surgeon,       Preanesthesia Assessment, Surgical Preparation and Verification of Site, etc.

·         What human factors were relevant to the event?

Evaluate the role of human performance factors that may have contributed to an error.

Example: Fatigue of staff involved, personal problems where staff was not focused on job tasks, complex critical thinking requiring knowledge based decisions, not following documented policy and procedure, substance abuse, stress, boredom or staff rushing to complete the task.

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List the various equipment utilized for that patient during the event in question.  To assist in evaluating these processes consider the following:

Was the equipment where it was supposed to be?  Why or why not? Was staff in-serviced on equipment? How long ago?  How frequently is the equipment used? Were alarms, displays, and controls identifiable and/or operating properly?  Is the equipment set-up and performing in accordance with the manufacturer’s recommendations? Were equipment parts defective?

 

Example:  The PCA pump had not had the scheduled preventive maintenance check completed.  The equipment was not functioning properly but the policy for marking defective equipment was not followed.  The PCA pump was put into the wrong storage area, along with properly functioning equipment, without posting a sign indicating the equipment was broken.  The equipment was then accessed for use on the patient.

 

• What controllable factors directly affected the outcome?

Identify factors that may have contributed to the event that the organization has the ability to change by making process improvement changes.

 

Example: Site was marked and the prep scrub washed off the marking prior to site verification.  Site verification did not occur with all involved, per organizational P&P (physician, nurse, anesthesiologist).

• Where there uncontrollable external factors?

Uncontrollable external factors are those factors that the organization cannot change that contribute to a breakdown in internal processes.  An organization should not be willing to assign many issues to this category.  Although a factor may be beyond the organization’s control, the organization may be able to minimize the factor’s effect on patients.

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Example: A hospital may not have control or be able to prevent circumstances that cause a power outage such as lightning striking or flooding, but it can plan for these occurrences and be prepared to generate back-up emergency power. Or, a power outage may be due to a car hitting an electrical pole outside the hospital and the organization has placed warning signs with blinking lights, which are located before the pole.

 

·         If appropriate, what other areas or services are impacted?

List all other areas that have the potential for a similar event to occur.  This will assist in implementing risk reduction strategies in other pertinent high-risk areas.

 

Example:  A wrong site surgery occurred in the main Operating Room.  A root cause analysis was conducted and various opportunities for improvements were implemented.  The Endoscopy area, Emergency room and any other area where a procedure is performed may be able to incorporate the recommendations for improvements to proactively prevent a similar occurrence.

·         To what degree is staff properly qualified and currently competent for their responsibilities?

Include all staff present, not just those that were determined to be involved with the event. Do not overlook physicians and allied health practioners/mid levels.  Determine if staff was formally trained to perform the specific duties or tasks involved in the event.  Was the training adequate?  Was staff qualified to use the equipment? Was there agency staff that may not have been familiar with procedures/equipment?  Was staff oriented to the organization and department specific policies/procedures?

 

 

Example: Physicians involved were appropriately privileged and credentialed.  All required individuals (eg, RNs, RRT, LPN) are licensed and competent based upon previous evaluations and skill requirements.  Agency and float staff has been appropriately oriented to the department/organization and do not have any performance issues.

·         How did actual staffing compare with ideal levels?

Was there appropriate staffing at the time of the event to address the required workload?  Keep in mind if it was a weekend, change of shift, holiday, break time.

Document the actual staffing in area of occurrence versus planned staffing according to the staffing model.  Explain any variation; higher or lower staffing.

Example: The staffing model for 26 patients required four RNs, one Patient care assistant, and one unit clerk.  Actual staffing included four RNs, two Patient Care Assistants and one unit clerk.  Actual staffing exceeded the required numbers.  However, three of the four RNs were participating in a staff meeting at the time of the event.

 

• To what degree is all information available when needed?

Was information from various patient assessments completed, shared, and accessed by members of the treatment team as required by policy?  Was the patient correctly identified?  Was the documentation clear and did it provide an adequate summary of the patient’s condition, treatment, and response to treatment?  Was the level of automation appropriate?  Identify what information systems were utilized during patient care.

Examples:

1. No instruction for use of neonatal ambu bag available on code cart or med room.
2. No policy and procedure for pump settings.
3. Transfer form reported at risk for falls. Notification missing on chart.
4. No allergies noted on chart.

• To what degree is communication among participants adequate?

Look at this content to cover verbal and lack of verbal/written communication(s).

1. Physician to….
2. Nurse to….
3. Tech to….
4. Pharmacist to….
5. Hierarchical issues….
6. Cultural issues….

And any other combination you can find during your investigation.

 

Example:  Respiratory Therapist did not communicate their unfamiliarity with the equipment to supervisor prior to patient care.  Why? Drill down.

Was communication of key information completed in a timely manner?  Was there a misunderstanding of information shared based on a language barrier, abbreviations, terminology, etc.?  Was shift-to-shift or unit-to-unit communication completed properly?  Were there adequate policies and procedures in place to describe what is required?  Is patient/family/significant other involved when needed in communication of information? Was adequate information communicated when a patient transferred from one area to another and was this communication of essential information documented?

• To what degree was the physical environment appropriate for the processes being carried out?

Look closely at the environment the patient was in or was transferred to/from. Spaces, privacy, safety, and ease of access are a few items to consider.  Was work performed under adverse conditions (hot, humid, improper lighting, cramped, noise, construction projects)?  Had there been environmental risk assessments conducted?  Did the work environment meet current codes, specifications, and regulations?  Was the work environment appropriate to support the function it was being used for?

 

Example:  Eight surgical suites have the head of the table facing north and the 9^th suite has the head of the bed facing south. Would redesign reduce the risk of wrong side surgery?  If a patient committed suicide by hanging a sheet from the top of the bathroom door, do you remove several inches off the door?  Drill down how did the patient obtain the sheet? Did patients have open access to the sheets?

 

• To what degree is the culture conducive to risk identification and reduction?

Did the overall culture of the facility encourage or welcome change, suggestions, and warnings from staff regarding risky situations or problematic areas?

 

Example:  Members of the management team, including the CEO, participate in attending meetings related to serious adverse events.  A confidential suggestion box and hotline have been established to report high-risk issues and each of these are read and evaluated by the management team.  Actions are taken on a regular basis.

 

• What can be done to protect against the effects of uncontrollable factors?

When looking at uncontrollable factors review the system the patient went through.

Example:

1. Power failure from thunderstorm.
2. EMTs arrive at the wrong door.
3. Patient denies substance abuse.
4. Physician had a flat tire.

• Prepare a Plan of Action (See Accreditation Process Guide for example)

 

-Specify Element of Performance Standard not in compliance, i.e. RI.1.20.

 

-Explain why standard not in compliance.

 

-Plan of Action:

Outline in detail the action plan steps taken to promote change.  Be specific.  If you change a policy and procedure, summarize the change that you are making.  Outline how you are going to implement the policy and procedure (e.g., educate staff, perform post test for staff, etc.).

 

-Person(s) Responsible for Implementation:

Identify by title the individual responsible for implementing the particular risk reduction step.

-Measures of Success:

Outline the plan for measuring the effectiveness of each risk reduction strategy.

• Indicators must be objective, measurable, and quantifiable. (Use outcome based measurements whenever possible)
• Measures of effectiveness need to have the data collection methodology outlined.
• Using a random sample? Define random.
• Give sample size and method of collecting.
• Are you determining effectiveness by observation? Pre-test/post-test? Pilot test? Audit tool? Explain.
• Set a target range that reflects the desired range of performance for each indicator

Examples of Measurement Strategies:

• Following a policy and procedure change, all nursing staff will demonstrate competency by passing posttest with score of 90% or higher and appropriately demonstrate 1 IV insertion.
• Individual physician complication rates for central catheter insertions will be less than 1%.
• 15 patients per day entering the ER, 3 per shift will be evaluated from time entering facility until time to treatment to determine average ER waiting times. All expected waiting times should be within 5 minutes for emergent patients and less than 3 hours for non-emergent patients.  (This example is not based on any national standards).
• Falls per 1000 patient days will be less than 2 per month
• Patient Satisfaction with pain management will be evidenced by level of 4 or above on Likert scale.

 

External comparisons may be used to develop indicator data and target measures.  Sources for external comparison data are performance measurement systems, professional organizations or societies and research articles.

Instructions:

1. Read the case study: Wandering Off the Floors: Safety and Security Risks of Patient Wandering at:

http://www.webmm.ahrq.gov/

 

2. Read the attached handout: JC Tool to Assist Organizations in the Completion of the Framework for Conducting a Root Cause Analysis

 

3. Review the Provision of Care, Treatment, and Services (PC) Elements of Performance (EP) standards found in the 2006 Accreditation Process Guide for Hospitals.

4. Prepare a typed, root cause analysis report and plan of action of the case following guidelines in the Tool to assist document to include:

 

• The report of the root cause analysis should be written in complete sentences. As appropriate address each bulleted item listed in the Tool to Assist Be sure to read each explanation and example (51 points). Points will be assigned on thoroughness of the analysis.

 

• Attach to the report plans of action. Use as an example plan of action found in 2008 Accreditation Process Guide for Hospitals (60 points). Points will be assigned based on:

 

• • Accurately citing JC Elements of Performance (EP) standard
  • Accurately describing root cause
  • Citing reasonable and practical plan of action
  • Correctly naming responsible person(s)
  • Providing realistic measure(s) of success (MOS)