1. ® Problem Solving for Root Cause Analysis An overview for CLARION Case Competition 2009 Presented by: Sandra Potthoff, Ph.D. Director of Program in Healthcare Administration School of Public Health University of Minnesota

2. ® CLARION Case Description of Organization Overview of Hospital and broader environmental context Topic Detailed description of care delivered to a patient that lead to a sentinel event Team Assignment Conduct a root cause analysis and present your recommendations and implementation plan for system changes to an interprofessional panel of judges

3. ® SENTINEL EVENT An unexpected occurrence involving death, serious physical or psychological injury, or risk thereof Occurrence results from a variation from the desired process Variation can have a common cause, special cause, or both Joint Commission (2003). Root Cause Analysis in Health Care: Tools and Techniques, 2 nd Edition.

4. ® HUMAN ERROR “Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects… Their part is adding the final garnish to a lethal brew that has been long in the cooking.” James Reason (1990) Human Error

5. ® VARIATION COMMON CAUSE: variation that occurs in processes because of the way a process is designed; typically at the blunt end of the system SPECIAL CAUSE: variation that occurs because of unusual circumstances in the process, for example, human error; typically at the sharp end of the system

6. ® SHARP END BLUNT END ORGANIZATIONAL CONTEXT Resources and Constraints Operational System as Cognitive System Errors and Expertise Cook and Woods (1994) Operating at the sharp end: the complexity of human error Human Error and Medicine

7. ® PROBLEM SOLVING PROCESS PROBLEM DEFINITION ROOT CAUSE ANALYSIS RECOMMENDED SOLUTIONS IMPLEMENTATION What happened? Why did it happen? (get to 5 th order why) How can this be prevented from happening again? Are solutions fixing the root causes? Who and how Time and budget Ongoing monitoring

8. ® PROBLEM DEFINITION ROOT CAUSE ANALYSIS: What happened? DETAILS OF THE SENTINEL EVENT Brief description When did the event occur What areas/services are impacted DIFFICULTIES DESCRIBED IN THE CASE List facts or opinions described in the case that indicate a difference between WHAT IS and WHAT OUGHT TO BE PROBLEM AREAS Group similar difficulties into problem areas What is the core issue in each problem area? (for example, how can hospital A achieve goal Y in light of constraints X, Y, and Z?)

9. ® PROBLEM DEFINITION ROOT CAUSE ANALYSIS: Why did it happen? MOST PROXIMATE FACTORS Flow diagram of process in which event occurred Where were the failures in the process REASONS FOR FAILURES Root causes by problem area “Initial Triage Questions” Root cause questions for typical problem areas 5 th ORDER WHY For every cause identified, keep asking why Ensure you get to the root cause, not just the symptoms

10. ® PROBLEM DEFINITION RECOMMENDED SOLUTIONS FIX THE ROOT CAUSES For each set of problem areas BARRIERS TO IMPLEMENTATION Are solutions viable given organizational and environmental constraints Are there stakeholders who will be opposed to the solutions and how will your change strategy address this?

11. ® PROBLEM DEFINITION IMPLEMENTATION ROLES AND RESPONSIBILITIES How will solutions be implemented? TIME AND BUDGET Are time frames reasonable given immediate and long term needs? What resources are required to implement the solutions? MONITORING How will you know if your solutions are having their intended effect? What will be monitored and how?

12. ® PROBLEM DEFINITION RESOURCE WEB SITES ROOT CAUSE ANALYSIS RESOURCE US Department of Veterans Affairs National Center for Patient Safety http://www.patientsafety.gov/rca.html Joint Commission Resources (2003). Root Cause Analysis in Health Care: Tools and Techniques, 2 nd Edition. http://www.jcrinc.com PATIENT SAFETY RESOURCE Institute for Healthcare Improvement http://www.ihi.org/ihi