Effective Investigations

Leading Age – St. LouisAugust 31, 2015

Why Investigate?

• Address system issues

• Address people issues

• Who is your audience?

What Will You Be Learning Today?

A structured process to identify causal or contributing factors underlying adverse events or other critical incidents to assist in identifying areas of focus for improvement to prevent the event from reoccurring.

A step by step questioning process to identify the basic or causal factors of an error or “near miss” – or any unsatisfactory outcome or potential outcome.

The end product: a plan of action that will eliminate or mitigate the risk of an event reoccurring

Don’t Over-Complicate Things

What You’re Looking For

• Fundamental reason(s) for the failure or inefficiency of one or more processes.

• Point(s) in the process where an intervention could reasonably be implemented to change performance and prevent an undesirable outcome.

• The majority of events have multiple root causes.

• Prioritize: what can you expect to improve?

Looking for the magic bullet?

Investigation: Key Definitions

o Active erroro Adverse evento Forcing functiono Human factorso Incident reportingo Near misso Sentinel evento Swiss cheese mode

o Triggers vs. trigger questions

The Vocabulary

• Cause: A cause is an “agency”, perhaps acting through a long time, or a long-standing situation, that produces an effect (Dictionary.com)

• Latent cause: An “agency” that has been around that adds to the risk, but hasn’t produced an effect—perhaps until now

• Common cause: An “agency” that is involved in more than one situation, not necessarily through the same pathway, often identified with statistics

• Root cause: digging below the surface.

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Investigation and Culture

What makes up culture?– Values– Attitudes– Beliefs

How is culture manifested?– Practices– Procedures– Policies– Routines of staff and leadership– Behaviors expected; behaviors that get rewarded

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Definition of Culture

The set of shared attitudes, values, goals and practices that characterizes an institution, organization or group

-- Merriam Webster

“The way we do things around here”

Culture-Based Investigation(With shout-out to Just Culture)

• What happened• What normally happens?• What does policy say should have happened?• What are the reasons for any gaps?• What are we doing to manage this?• Have we selected a good solution?

Where to Begin? Learn What Happened.

• What is your policy & process for investigating adverse events and near misses? Do you have one? Does it work?

• Determine the FACTS & timeline of the event in question.• What are risks and benefits of one-on-one interviews vs.

group de-briefing. One-on-one is usually better.• Make sure everyone knows the purpose and that it’s a safe

place to share.• Who needs to be present to support staff?• Does the resident or family have relevant information?• This may take a couple of rounds

De-briefing: Just the Facts

• Start with introductions: members of the group & the process• One or two interviewers; two makes it easier to get good

notes• Use open-ended questions• Prepare attendees prior to the debriefing: purpose and

ground rules• Keep focused on the deliverable outcome of the debriefing:

Facts.• Don’t commingle this stage with system analysis and action

planning. Use parking lots.• This includes “what normally happens?”

System Investigation Process: Organize a Team

• Top Leadership’s Role:– Commitment of resources– Empowering team to transform processes

• Team member selection:– Include staff at all levels closest to the issues involved in

the situation– Individuals critical to implementation of change– A leader with broad knowledge base– Individuals with diverse knowledge

• Refer to QAPI structure, fit this in

Ground Rules for the Team

• Review the purpose of investigation… to change the system to minimize risk to those in our care

• Everyone is a professional, all are equal

• No sacred cows

• Treat each other with respect

• Validate concerns, but stay on task

• Be open-minded; speak candidly and honestly

• Confidentiality - What is said in the room, about who said or did what, stays in the room.

• Individual behaviors and decisions are dealt with elsewhere

Tools

• Learning From Defects• Five Why’s• Fishbone• Category Table• THESE ARE JUST TOOLS

TO HELP YOU THINK• IF IT’S DONE RIGHT, THE

ANSWERS ARE THE SAME

Determine the “Root Cause”

• Describe relevant process in detail- process map usually helps (see example)

• Ask questions• Strong listening process for answers• Amplification where necessary – empower • Group into categories of causal factors (see fishbone):

– Human factors – communication, fatigue, staffing– Environment/Equipment– Rules/Policies/Procedures– Information management– Culture

• Include “Parking Lot” for incidental findings

Root Causes of Sentinel Event Reported to TJC

http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2Q2013.pdf

Human Factors

From Dictionary.com:

an applied science that coordinates the design of devices, systems, and physical working conditions with the capacities and requirements of the worker

Our Values

• Overlapping Duties?Yes

• Competing Duties?Yes

• We Must Prioritize and Balance in Support of Our Values

Access to Care

Compassion/ Resident rights

Fiscal ResponsibilityPrivacy

Safety

You want to land here

Develop Risk Reduction/Action Plan

• Prioritize• For each cause, identify:

• corrective measures • improvement opportunities• SMART

• Create a timeline• Assign accountability for

implementation• Designate a team to oversee

follow-up• Develop reporting schedule

Explore Solutions

• Use an engineering approach to failure prevention

• Start with the premise that anything that could go wrong will go wrong

• Design systems that make it difficult for individuals to err

• Build in as much redundancy as possible

• Use fail-safe design whenever possible

• Simplify processes

• Consider ad-hoc team members - Resources

Designing Effective Systems

Controlling Contributing Factors • Trying to change the pre-cursors to human

error and at-risk behavior

Adding Barriers • Trying to prevent individual errors

Adding Recovery • Trying to catch errors downstream

Adding Redundancy • Trying to add parallel elements

Exercise

For each example below, describe the one or two principal design strategies used to manage the risk, then and now.

1. Needle Stick• 20 years ago:• Today:

2 IV Medication administration• 20 years ago:• Today:

3 Resident getting out of bed without assistance• 20 years ago:• Today:

4 Personal protection from disease or injury• 20 years ago:• Today:

5 Back injury during lifting• 20 years ago:• Today:

6 Safe and Effective CPR• 20 years ago:• Today:

Action Plan

Problems/ Opportunities

Improvement Strategy

Responsible Individual(s)

Implementation Timeline/ Deadline Measurement Strategy Reporting to/

dates

Communication between shifts

Scripted handoff with required input from various staff

CNA 1 CNA 2 RN

June 15 team meet

July 1 tool developed and policy drafted. Begin trial with Cedar Ridge unit

July 15 initial measurement

Revise as necessary; retest

Observation Compliance with

care plans Reduction in

____ events Feedback from

staff

PIP team: 8/1, 9/1

QAPI oversight team 9/15

CPS’ Root Cause Analysis Tool

CPS’ Root Cause Analysis Tool

The Guts of the Process

Don’t Forget the Background and “Soft” Stuff

System Processes Training Accountability Equipment and design Procedure development Choosing the right people Dealing with human error -

policies

Values and Relationships Priorities and how they are

communicated Response to incidents Coaching and teamwork What is rewarded or

sanctioned? What drives promotions

and terminations?

Exercise

• Volunteers for role play• Perform interviews – groups based on attendance

– Group interview or individual?• Design action plan• Design follow-up measurements

FMEA: Investigating the Event that Hasn’t Happened

• Select a high-risk process and assemble a team• Diagram the process (really…draw pictures)

– Observation/mapping– Interviews

• Conduct a hazard analysis: what could go wrong and why?• Consider severity and probability of hazards; prioritize.• Remember to include people who have their hands in the

process• Action plans• Parking lot

Process Flow

VA National Center for Patient Safety: The Basics of Healthcare Failure Mode and Effect Analysis

Which is Best?

• Root Cause Analysis• FMEA• Parking Lot• Personnel Management• Send to attorney or insurance co.

Closing the Loop

Always get back to the person who brought up the issue in the first place.

The Role of the Patient Safety Organization

• Investigation coaching assistance for participants

• Aggregate information about events: numbers, root causes and action plans

• Work together with other PSO participants on common problems—compare experiences

• Special projects, e.g. falls with injury/ likely injury and high-risk medication events

• Confidential space for all this work

• Safety watches and alerts

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Questions?

Contact:

Kathryn WireCenter for Patient Safety

kwire@mocps.org(314) 540-4910

www.centerforpatientsafety.org