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Critical Event Review (Root Cause Analysis)

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Presentation on theme: "Critical Event Review (Root Cause Analysis)"— Presentation transcript:

1 Critical Event Review (Root Cause Analysis)
Hutchinson Area Health Care December 2008

2 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 in Long Term Care - Process Story

3 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

4 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

5 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

6 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

7 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

8 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

9 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 Admin. Assistant schedules – tell briefly why important to come (to reduce fear of unknown)

10 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 Talk about example – hospice, community involvement, etc.

11 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 TALK ABOUT BARRIERS – OVERTIME, DON’T WANT TO COME IN

12 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

13 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

14 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

15 Meeting Format Introductions and Ground Rules Brief orientation to CER
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

16 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?

17 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

18 Forms

19 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

20 Spread the Success/knowledge
Share with staff and Administration Need to go beyond interdisciplinary care team Potential: Share learnings and collaborate with other facilities NPSG’s Mattress

21 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

22 Questions? Thank you!

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