Root Cause Analysis And Improvement In The Healthcare Sector

Author : Bjørn Andersen,Marti Beltz
Publisher : Quality Press
Page : 257 pages
File Size : 40,5 Mb
Release : 2009-11-09
Category : Business & Economics
ISBN : 9780873891257

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Root Cause Analysis and Improvement in the Healthcare Sector by Bjørn Andersen,Marti Beltz Pdf

Healthcare organizations and professionals have long needed a straightforward workbook to facilitate the process of root cause analysis (RCA). While other industries employ the RCA tools liberally and train facilitators thoroughly, healthcare has lagged in establishing and resourcing a quality culture. Presently, a growing number of third-party stakeholders are holding access to accreditation and reimbursement pending demonstration of a full response to events outside of expected practice. An increasing number of exceptions to healthcare practice have precipitated a strong response advocating the use of proven quality tools in the industry. In addition, the industry has now expanded its scope beyond the hospital walls to many ancillary healthcare facilities with little experience in implementing quality tools. This book responds to the demand for a RCA workbook written specifically for healthcare, yet still broad in its definition of the industry. This book contains everything that the typical RCA leader in healthcare requires: A text specific to healthcare, but using the broadest definition of the industry to include not only acute care hospitals, but rehabilitation facilities, long-term care facilities, outpatient surgery centers, ambulatory services, and general office practices. A workbook-style format that walks through the process, step-by-step. Straightforward text without “sidebars,” “tables,” and “tips.” Worksheets are provided at the end of the book to reduce reader distraction within the text. A wide range of real-world examples. Format for use by the most naive of users and most basic of processes, as well as a separate section for more advanced users or more complex issues. Templates, both print and electronic, included for the reader’s use. Ready-to-use educational materials with scripting to enable the user to train others and garner support for the use of the techniques. Background text for users in leadership to understand the tools in the larger context of healthcare improvement. Up-to-date information on the latest in the use of RCA in satisfying mandatory reporting requirements and slaying the myth that the process is onerous and fraught with barriers. Background text and tools/process are separated to facilitate the readers’ specific needs. Healthcare leaders can appreciate the current context and requirements without wading through the actual techniques; end-users can begin learning the skills without wading through dense administrative text. Language and tone promoting the use of the tools for improvement of processes that have experienced exceptions, as opposed to assigning blame for errors. Attention to process ownership, training, and resourcing. And, most importantly, thorough description of the improvement process as well as the analysis.

Author : Bjorn Andersen,Martha Ellen Keyes Beltz,Tom Natland Fagerhaug
Publisher : Quality Press
Page : 257 pages
File Size : 45,5 Mb
Release : 2009-11-09
Category : Business & Economics
ISBN : 9781636942001

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Root Cause Analysis and Improvement in the Healthcare Sector by Bjorn Andersen,Martha Ellen Keyes Beltz,Tom Natland Fagerhaug Pdf

Healthcare organizations and professionals have long needed a straightforward workbook to facilitate the process of root cause analysis (RCA). While other industries employ the RCA tools liberally and train facilitators thoroughly, healthcare has lagged in establishing and resourcing a quality culture. Presently, a growing number of third-party stakeholders are holding access to accreditation and reimbursement pending demonstration of a full response to events outside of expected practice. An increasing number of exceptions to healthcare practice have precipitated a strong response advocating the use of proven quality tools in the industry. In addition, the industry has now expanded its scope beyond the hospital walls to many ancillary healthcare facilities with little experience in implementing quality tools. This book responds to the demand for a RCA workbook written specifically for healthcare, yet still broad in its definition of the industry. This book contains everything that the typical RCA leader in healthcare requires: A text specific to healthcare, but using the broadest definition of the industry to include not only acute care hospitals, but rehabilitation facilities, long-term care facilities, outpatient surgery centers, ambulatory services, and general office practices. A workbook-style format that walks through the process, step-by-step. Straightforward text without “sidebars,” “tables,” and “tips.” Worksheets are provided at the end of the book to reduce reader distraction within the text. A wide range of real-world examples. Format for use by the most naive of users and most basic of processes, as well as a separate section for more advanced users or more complex issues. Templates, both print and electronic, included for the reader’s use. Ready-to-use educational materials with scripting to enable the user to train others and garner support for the use of the techniques. Background text for users in leadership to understand the tools in the larger context of healthcare improvement. Up-to-date information on the latest in the use of RCA in satisfying mandatory reporting requirements and slaying the myth that the process is onerous and fraught with barriers. Background text and tools/process are separated to facilitate the readers’ specific needs. Healthcare leaders can appreciate the current context and requirements without wading through the actual techniques; end-users can begin learning the skills without wading through dense administrative text. Language and tone promoting the use of the tools for improvement of processes that have experienced exceptions, as opposed to assigning blame for errors. Attention to process ownership, training, and resourcing. And, most importantly, thorough description of the improvement process as well as the analysis.

Author : David Allison, CPPS,Harold Peters, P.Eng.
Publisher : CRC Press
Page : 142 pages
File Size : 48,8 Mb
Release : 2021-08-24
Category : Technology & Engineering
ISBN : 9781000430059

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Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient Safety by David Allison, CPPS,Harold Peters, P.Eng. Pdf

The book follows a proven training outline, including real-life examples and exercises, to teach healthcare professionals and students how to lead effective and successful Root Cause Analysis (RCA) to eliminate patient harm. This book discusses the need for RCA in the healthcare sector, providing practical advice for its facilitation. It addresses when to use RCA, how to create effective RCA action plans, and how to prevent common RCA failures. An RCA training curriculum is also included. This book is intended for those leading RCAs of patient harm events, leaders, students, and patient safety advocates who are interested in gaining more knowledge about RCA in healthcare.

Author : Bjørn Andersen,Tom Fagerhaug
Publisher : Quality Press
Page : 306 pages
File Size : 40,7 Mb
Release : 2006-01-01
Category : Business & Economics
ISBN : 9780873896924

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Root Cause Analysis, Second Edition by Bjørn Andersen,Tom Fagerhaug Pdf

This updated and expanded edition discusses many different tools for root cause analysis and presents them in an easy-to-follow structure: a general description of the tool, its purpose and typical applications, the procedure when using it, an example of its use, a checklist to help you make sure if is applied properly, and different forms and templates (that can also be found on an accompanying CD-ROM). The examples used are general enough to apply to any industry or market. The layout of the book has been designed to help speed your learning. Throughout, the authors have split the pages into two halves: the top half presents key concepts using brief language—almost keywords—and the bottom half uses examples to help explain those concepts. A roadmap in the margin of every page simplifies navigating the book and searching for specific topics. The book is suited for employees and managers at any organizational level in any type of industry, including service, manufacturing, and the public sector.

Author : National Academies of Sciences, Engineering, and Medicine,Health and Medicine Division,Board on Population Health and Public Health Practice,Committee on Community-Based Solutions to Promote Health Equity in the United States
Publisher : National Academies Press
Page : 583 pages
File Size : 46,6 Mb
Release : 2017-04-27
Category : Medical
ISBN : 9780309452960

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Communities in Action by National Academies of Sciences, Engineering, and Medicine,Health and Medicine Division,Board on Population Health and Public Health Practice,Committee on Community-Based Solutions to Promote Health Equity in the United States Pdf

In the United States, some populations suffer from far greater disparities in health than others. Those disparities are caused not only by fundamental differences in health status across segments of the population, but also because of inequities in factors that impact health status, so-called determinants of health. Only part of an individual's health status depends on his or her behavior and choice; community-wide problems like poverty, unemployment, poor education, inadequate housing, poor public transportation, interpersonal violence, and decaying neighborhoods also contribute to health inequities, as well as the historic and ongoing interplay of structures, policies, and norms that shape lives. When these factors are not optimal in a community, it does not mean they are intractable: such inequities can be mitigated by social policies that can shape health in powerful ways. Communities in Action: Pathways to Health Equity seeks to delineate the causes of and the solutions to health inequities in the United States. This report focuses on what communities can do to promote health equity, what actions are needed by the many and varied stakeholders that are part of communities or support them, as well as the root causes and structural barriers that need to be overcome.

Author : Anonim
Publisher : Joint Commission on
Page : 174 pages
File Size : 51,9 Mb
Release : 2000-01-01
Category : Health facilities
ISBN : 0866886419

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Root Cause Analysis in Health Care by Anonim Pdf

Despite remarkable advances in almost every field of medicine, an age-old problem continues to haunt health care professionals - the occurence of errors. This book aims to help health care organizations prevent systems failures by using root cause analysis to identify causes of a sentinal event, to implement risk-reduction strategies which decrease the likelihood of a recurrence of the event, and to identify effective and efficient ways of improving performance. Root cause analysis is an effective tool used both reactively to investigate an adverse event that already has occurred, and proactively, to analyze and improve processes and systems before they break down.

Author : Mark A. Latino,Robert J. Latino,Kenneth C. Latino
Publisher : CRC Press
Page : 332 pages
File Size : 46,7 Mb
Release : 2019-06-26
Category : Business & Economics
ISBN : 9780429822117

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Root Cause Analysis by Mark A. Latino,Robert J. Latino,Kenneth C. Latino Pdf

This book comprehensively outlines what a holistic and effective Root Cause Analysis (RCA) system looks like. From the designing of the support infrastructure to the measuring of effectiveness on the bottom-line, this book provides the blueprint for making it happen. While traditionally RCA is viewed as a reactive tool, the authors will show how it can be applied proactively to prevent failures from occurring in the first place. RCA is a key element of any successful Reliability Engineering initiative. Such initiatives are comprised of equipment, process and human reliability foundations. Human reliability is critical to the success of a true RCA approach. This book explores the anatomy of a failure (undesirable outcome) as well as a potential failure (high risks). Virtually all failures are triggered by errors of omission or commission by human beings. The methodologies described in this book are applicable to any industry because the focus is on the human being's ability to think through why things go wrong, not on the industry or the nature of the failure. This book correlates reliability to safety as well as human performance improvement efforts. The author has provided a healthy balance between theory and practical application, wrapping up with case studies demonstrating bottom-line results. Features Outlines in detail every aspect of an effective RCA ‘system’ Displays appreciation for the role of understanding the physics of a failure as well as the human and system’s contribution Demonstrates the role of RCA in a comprehensive Asset Performance Management (APM) system Explores the correlation between Reliability Engineering and Safety Integrates the concepts of Human Performance Improvement, Learning Teams, and Human Error Reduction approaches into RCA

Author : Institute of Medicine,Committee on Quality of Health Care in America
Publisher : National Academies Press
Page : 312 pages
File Size : 40,6 Mb
Release : 2000-03-01
Category : Medical
ISBN : 9780309068376

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To Err Is Human by Institute of Medicine,Committee on Quality of Health Care in America Pdf

Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

Author : Gerard Magill,Lawrence Prybil
Publisher : Routledge
Page : 220 pages
File Size : 48,8 Mb
Release : 2020-01-28
Category : Medical
ISBN : 9781000036336

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Governance Ethics in Healthcare Organizations by Gerard Magill,Lawrence Prybil Pdf

Drawing on the findings of a series of empirical studies undertaken with boards of directors and CEOs in the United States, this groundbreaking book develops a new paradigm to provide a structured analysis of ethical healthcare governance. Governance Ethics in Healthcare Organizations begins by presenting a clear framework for ethical analysis, designed around basic features of ethics – who we are, how we function, and what we do – before discussing the paradigm in relation to clinical, organizational and professional ethics. It goes on to apply this framework in areas that are pivotal for effective governance in healthcare: oversight structures for trustees and executives, community benefit, community health, patient care, patient safety and conflicted collaborative arrangements. This book is an important read for all those interested in healthcare management, corporate governance and healthcare ethics, including academics, students and practitioners.

Author : Robert J. Latino
Publisher : CRC Press
Page : 192 pages
File Size : 48,6 Mb
Release : 2008-10-14
Category : Technology & Engineering
ISBN : 1420087282

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Patient Safety by Robert J. Latino Pdf

Are you ready and willing to get to the root causes of problems? As Medicare, Medicaid, and major insurance companies increasingly deny payment for never events, it has become imperative that hospitals and doctors develop new ways to prevent these avoidable catastrophes from recurring. Proactive tools such as root cause analysis (RCA), basic failure mode and effects analysis (FMEA), and opportunity analysis (OA) are useful in preventing error, but in healthcare, such tools are often constrained by reticence to share information about mistakes and other problems inherent to the industry. ...well written and extremely applicable to health care. Every healthcare professional should have a copy. - Matthew C. Mireles, President / CEO, Community Medical Foundation for Patient Safety, Bellaire, Texas Patient Safety: The PROACT® Root Cause Analysis Approach addresses the proactive methodologies and organizational paradigms that must change in order to support and sustain such activities in the interest of patient safety. Written by reliability expert Robert J. Latino, this book provides a perspective on patient care from outside the health industry and culture. It teaches a proven approach that measures its effectiveness based on patient safety results, rather than compliance, and demonstrates the Return-On-Investment for using RCA to reduce and/or eliminate undesirable outcomes. Addressing the contribution of human error to physical consequences, Latino explores ways to identify conditions that are more prone to result in human error. It also uses FMEA to proactively identify unacceptable risks, and then uses the concepts of RCA to prevent risks from materializing. Are you ready to be tenacious in your approach and completely honest in your assessment? Root Cause Analysis requires courage and honesty. When properly applied RCA will point out the problems and lead you to solutions. Visit the author's website; find out if RCA is right for your organization Robert J. Latino has spent the past 10 years researching the differences in industrial culture versus the healthcare culture. In this book, he expertly makes the appropriate modifications to proven methodologies to successfully bridge the proactive technologies from industry to healthcare. Additional information, including an audio-visual presentation by the author, is available on the PROACT website at http://www.proactforhealthcare.com

Author : Joint Commission Resources, Inc Staff
Publisher : Joint Commission on
Page : 216 pages
File Size : 55,8 Mb
Release : 2005-05-01
Category : Medical
ISBN : 0866889361

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Root Cause Analysis in Health Care by Joint Commission Resources, Inc Staff Pdf

Author : Michael Wiklund,Andrea Dwyer,Erin Davis
Publisher : CRC Press
Page : 267 pages
File Size : 49,5 Mb
Release : 2016-01-06
Category : Medical
ISBN : 9781498705806

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Medical Device Use Error by Michael Wiklund,Andrea Dwyer,Erin Davis Pdf

Medical Device Use Error: Root Cause Analysis offers practical guidance on how to methodically discover and explain the root cause of a use error-a mistake-that occurs when someone uses a medical device. Covering medical devices used in the home and those used in clinical environments, the book presents informative case studies about the use errors

Author : Stijn Kelchtermans,Filip de Beule
Publisher : Academic Conferences Limited
Page : 854 pages
File Size : 54,7 Mb
Release : 2013
Category : Entrepreneurship
ISBN : 9781909507593

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Proceedings for the 8th Europen Conference on Innovation and Entrepreneurship by Stijn Kelchtermans,Filip de Beule Pdf

Author : M.K. Widmer,J. Malik
Publisher : Karger Medical and Scientific Publishers
Page : 270 pages
File Size : 53,9 Mb
Release : 2015-02-11
Category : Medical
ISBN : 9783318027068

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Patient Safety in Dialysis Access by M.K. Widmer,J. Malik Pdf

Not only are dialysis access creation and maintenance prone to complications, but patients suffering from end-stage renal disease and its comorbidities generally have a high risk of adverse events during their continuous treatment. Preventive strategies are key to avoid harm and to improve the outcome of the treatment of the growing number of patients with chronic kidney failure, especially as doctors and nurses are not always aware of the consequences of unsafe behavior. This publication is intended for health care professionals – nurses as well as doctors – and aims to raise the awareness of patient safety aspects, combining medical education with evidence-based medicine. After a general overview of the topic, an international panel of authors provides a diversified insight into important concepts and technical tricks essential to create and maintain a functional dialysis access.

Author : Kenneth C. Latino,Mark A. Latino,Robert J. Latino
Publisher : CRC Press
Page : 95 pages
File Size : 47,5 Mb
Release : 2020-09-10
Category : Business & Economics
ISBN : 9781000178265

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The PROACT® Root Cause Analysis by Kenneth C. Latino,Mark A. Latino,Robert J. Latino Pdf

Root Cause Analysis, or RCA, "What is it?" Everyone uses the term, but everyone does it differently. How can we have any uniformity in our approach, much less accurately compare our results, if we’re applying different definitions? At a high level, we will explain the difference between RCA and Shallow Cause Analysis, because that is the difference between allowing a failure to recur or dramatically reducing the risk of recurrence. In this book, we will get down to basics about RCA, the fundamentals of blocking and tackling, and explain the common steps of any investigative occupation. Common investigation steps include: Preserving evidence (data)/not allowing hearsay to fly as fact Organizing an appropriate team/minimizing potential bias Analyzing the events/reconstructing the incident based on actual evidence Communicating findings and recommendations/ensuring effective recommendations are actually developed and implemented Tracking bottom-line results/ensuring that identified, meaningful metrics were attained We explore, "Why don’t things always go as planned?" When our actual plans deviate from our intended plans, we usually experience some type of undesirable or unintended outcome. We analyze the anatomy of a failure (undesirable outcome) and provide a step-by-step guide to conducting a comprehensive RCA based on our 3+ decades of applying RCA as we have successfully practiced it in the field. This book is written as a how-to guide to effectively apply the PROACT® RCA methodology to any undesirable outcome, is directed at practitioners who have to do the real work, focuses on the core elements of any investigation, and provides a field-proven case as a model for effective application. This book is for anyone charged with having a thorough understanding of why something went wrong, such as those in EH&S, maintenance, reliability, quality, engineering, and operations to name just a few.