Root Cause Analysis For Healthcare

Administrators and quality professionals in the healthcare field recognize the need beyond sentinel events for ongoing activities and priorities that are geared toward broad improvement of operations. When professionals have adopted this broader view of operations improvement into their decision equation for root cause analysis, several dimensions are introduced into the decision.

We know that a busy day takes on a whole new meaning when that day is in the healthcare field. When the goal is to have capability to perform root cause analysis on only the unusual occurrence of a sentinel event, there are certain demands upon time for training and scheduling that usually affect a few persons at the facility once in a while. However, when both occasional sentinel event analysis and the routine analysis of every-day counter-quality problems are included in the root cause analysis strategy, the concerns of time,  scheduling and numbers of personnel become a different issue. How does the quality professional, who wants to deploy root cause analysis as a part of the strategy for operations improvement in the healthcare environment, deal with this dilemma?  We have a practical answer.

Root cause analysis can be fine tuned. REASON sees this challenge as an issue of balancing available time and effort with value and benefit. To accomplish this balance, REASON Root Cause Analysis provides a scaleable process that enables you to match the analysis time and effort to the significance of the problem: REASON FrontLine for minor issues, REASON Express for important issues, and REASON Pro for critical and sentinel event issues. As the criticality of the problem increases, you just turn up the heat with REASON Root Cause Analysis..

 The first step in the REASON Root Cause Analysis software process is to assess the degree of risk associated with the problem.

• If the problem is an annoying, everyday obstacle that an attendant shakes his head at, and quietly mutters to himself about, it is a candidate for using REASON Root Cause Analysis in the FrontLine Mode. In just a few minutes he is led by a simple wizard to state the problem, the causes, and a business process that will correct the problem. In the past, such issues might have gone unaddressed because there was not a quick and convenient way to deal with them.

• If a nurse on late-night duty realizes that a patient may be caused discomfort because there was the possibility of crossing tubes accidentally when she was setting up a piece of treatment equipment, REASON Root Cause Analysis in Express Mode would serve to pinpoint how and why this potential was allowed into the environment and what to do to deal with the problem. A solution would be found that would not rely every time upon the personal late-night alertness of a nurse.

• If the criteria for sentinel event root cause analysis are met, or when other major event issues exist, REASON Root Cause Analysis in Pro Mode is required. It provides the world’s most exact and accurate method for root cause analysis. This is the mode used by the United Space Alliance on space shuttle issues, by Los Alamos National Laboratory of nuclear issues, and by the international team that analyzed the 2003 electric power outage that impacted homeland security and defense issues. When lives are in the balance, REASON Pro leads you strongly step-by-step, checks you for accuracy at each step and discovers the systemic root causes and the best solutions to the problem . . . the first time. Then professional analysis, narrative, and analytical model are generated instantly by the expert system for compliance documentation. With REASON Root Cause Analysis Pro you are prepared to manage whatever the crisis may present.

Time saving, efficiency and effectiveness are among the design criteria that produced REASON Root Cause Analysis. At each phase of deployment and application, these same criteria form the design of our training options for conveyance of root cause analysis skills to our clients.

Value From REASON: 

Lessons Learned     For organizations with many functions, operations and facilities, REASON Root Cause Analysis maximizes your benefit and value every time it is used. When a problem is analyzed, the knowledge gained from the analysis flows into your REASON Lessons Learned System. Key personnel among the facilities have submitted a data profile of all issues about which they are concerned, of materials they use, and of the processes in which they make decisions. Your REASON Lessons Learned System then watches incoming data, looking for matches to the data profiles. When a match is found, REASON sends an immediate email alert to the appropriate personnel. In minutes, vital information is in the hands of persons who need the data to deal with potential and developing problems in their areas. Also, the data can be accessed when questions arise on the floor, in order to avoid the past mistakes of others.

Flexible Deployment   Root cause analysis training options provide maximum flexibility. We offer a variety of root cause analysis training options: on your site, training at our facilities, and via WebCast over the Internet. These options include flexible, special scheduling of WebCast classes. Students can participate from different locations. These specially scheduled 16-hour WebCast classes can divided into four 4-hour segments on different days, or two 8-hour classes in different weeks . . . whatever works best for you. Click For Details.

A Strategy That Works  The key to deploying a successful operations problem-solving strategy in Healthcare is to acknowledge the reality of the environment and design the program to provide the three essential ingredients that facilitate success:

1.      Spread the Load  Root cause analysis for some types of organizations can be deployed as a responsibility to an assigned root cause analysis problem-solver to deal with reported problems, but a healthcare facility is not one of them. There are several reasons why you should aim for a crack team of problem solvers drawn from each of the key functions of your facilities. The critical nature of most issues places time restraints on activities, and demands professional and experienced input. Each function should have its own on-going effort to remove counter-quality, so that issues important to each need not vie with other functions for priority and attention. Equally important, when crisis threatens, there will be a multidiscipline team of experts in place with intimate knowledge of all key functions ready to deploy. 

2.      Assure Skills and Tools  Root cause analysis skill should be measurable, so that  you can accurately assess, certify and document the individual skill of each team member. This requires that your root cause analysis problem solving methodology provides criteria for accuracy and completeness, and provides a means beyond personal opinions to demonstrate and verify accuracy.

3.      Provide Oversight   Root cause analysis programs that are voluntary just don’t work in time-stressed environments. Well-intentioned persons, given critical responsibilities and maximum activity, will rarely find time for discretionary duties. Voluntary, in this case, means not important enough to monitor and measure. There will of course be no problem in getting the sentinel event handled, because it is not voluntary, but all of those less-then-sentinel events will rarely receive attention unless operations improvement activity in general is formalized, required, monitored and enforced. It is a fact of life for healthcare facilities.

Root cause analysis flexibility is a key to immediate and sustaining success of your root cause analysis activity. REASON is a flexible tool that works on big and little, simple and complex issues. Flexible deployment options meet the special needs of your organization. Technical and training support is available by phone, fax and email. When you need a pro on your team, we will be there. We have the root cause analysis experience, expertise, personnel, methodology and tools to help you plan and implement the root cause analysis system that will cost-effectively best fit your needs now and for the future.

Root cause analysis information dsi@rootcause.com or call 903 236 9973

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