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Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient Safety [Hardback]

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  • Formāts: Hardback, 126 pages, height x width: 234x156 mm, weight: 340 g, 23 Line drawings, black and white; 2 Halftones, black and white; 25 Illustrations, black and white
  • Izdošanas datums: 24-Aug-2021
  • Izdevniecība: CRC Press
  • ISBN-10: 1032035927
  • ISBN-13: 9781032035925
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  • Cena: 119,73 €
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Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient SafetyPalielināt
  • Formāts: Hardback, 126 pages, height x width: 234x156 mm, weight: 340 g, 23 Line drawings, black and white; 2 Halftones, black and white; 25 Illustrations, black and white
  • Izdošanas datums: 24-Aug-2021
  • Izdevniecība: CRC Press
  • ISBN-10: 1032035927
  • ISBN-13: 9781032035925
Citas grāmatas par šo tēmu:
Permanent link: https://www.kriso.lv/db/9781032035925.html
Keywords:
"The book follows a proven training outline, including real-life examples and exercises to teach healthcare professionals how to lead effective and successful Root Cause Analysis (RCA) to eliminate patient harm. This book discusses the need for Root Cause Analysis in the healthcare sector, providing practical applications for its facilitation. It also suggests how to construct an effective RCA action plan and when it is appropriate to employ an RCA. Real-examples and exercises are included. This book is intended for healthcare professionals as well as students who are interested in gaining more knowledge on the RCA process and how it relates to healthcare"--

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 Root Cause Analysis 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 Root Causes Analyses of patient harm events, leaders, students, and patient safety advocates who are interested in gaining more knowledge about RCA in healthcare.



The book follows a proven training outline, including real-life examples and exercises to teach healthcare professionals how to lead effective and successful Root Cause Analysis (RCA) to eliminate patient harm.

Recenzijas

"The main strengths of the materials are that they are practical, thorough and readily applicable to healthcare. The materials provide tools necessary for successful RCA performance and action plan implementation based on the authors years of experience leading the analysis of actual patient safety events in healthcare. The materials emphasize the importance of learning from adverse events to an organizations culture of safety. The authors place the patient at the center and also recognize the importance of credible event investigation to caregivers. The materials appropriately emphasize a systems approach to medical errors, the importance of reliably identifying the root cause of an event and implementing an action plan that prevents the error from recurring."

- Andrea Halliday, MD, Former Chief Clinical Officer Peace Health and PeaceHealth Oregon Network CMO (retired)

Preface xi
Acknowledgments xiii
Authors xv
PART I Building an Understanding of RCA
Chapter 1 The Need for Root Cause Analysis (RCA)
3(8)
1.1 Why Investigate Healthcare Unintended Events?
3(1)
1.2 Caring for Caregivers
3(1)
1.3 Systems Approach
4(3)
1.3.1 Aviation's Breakthrough
5(2)
1.4 Leadership Support for a Culture of Safety
7(1)
1.4.1 Leadership Responsibility for RCA
7(1)
1.5 Patients at the Center
8(1)
1.6 Questions to Consider
9(2)
Chapter 2 Forms of Analysis
11(12)
2.1 Troubleshooting
11(1)
2.2 Simple Problem-Solving
11(1)
2.3 Complex Problem-Solving
12(1)
2.4 A3 Thinking
12(1)
2.5 5 Whys
12(1)
2.6 Failure Modes and Effects Analysis
13(1)
2.7 Case Quality Review
14(1)
2.8 Apparent-Cause Analysis
14(1)
2.9 Logic Tree
14(1)
2.10 Meta-Analysis
15(1)
2.11 Peer Review
15(1)
2.12 Morbidity and Mortality Conference
16(1)
2.13 Summary of the Different Forms
16(1)
2.14 Selecting the Form of Analysis
16(2)
2.15 Forms of RCA
18(4)
2.15.1 Telephone Cutover Disaster: A Case Study
18(1)
2.15.2 5 Whys, Fishbone, and Bimodal Methods
19(3)
2.16 Questions to Consider
22(1)
Chapter 3 Pre-Work for an RCA Team Meeting
23(14)
3.1 Early Investigation and Preservation of Evidence
23(3)
3.2 Tasks in Preparation
26(9)
3.2.1 Denning Serious Safety Events
27(1)
3.2.2 Ordering the Team
27(3)
3.2.3 The Chronology
30(1)
3.2.4 The Logic Tree Top Box
31(2)
3.2.5 Top Boxes with Two Modes
33(1)
3.2.6 Logistics
34(1)
3.3 Exercise 1: Chronology
35(1)
3.4 Summary
36(1)
3.5 Questions to Consider
36(1)
Chapter 4 Creating the Logic Tree
37(24)
4.1 Logic Tree Root Causes
37(3)
4.1.1 Exercise 2: Types of Roots
39(1)
4.2 Logic Tree Hypothesizing
40(5)
4.2.1 Hypotheses
40(2)
4.2.2 How Could versus Why
42(1)
4.2.3 Two Approaches to Hypothesizing
43(1)
4.2.4 Boolean Logic
44(1)
4.3 Risks Associated with Hypothesizing
45(3)
4.3.1 Categories versus Hypotheses
45(1)
4.3.1.1 Countermeasure
45(1)
4.3.2 Latent Roots as Hypotheses
46(1)
4.3.2.1 Countermeasure
46(1)
4.3.3 Hypotheses Are Too Broad
46(1)
4.3.3.1 Countermeasure
47(1)
4.3.4 Hypotheses Are Too Narrow
47(1)
4.3.4.1 Countermeasure
48(1)
4.4 The Importance of Facilitating Hypothesizing
48(2)
4.4.1 Exercise 3: Hypothesis Generation
50(1)
4.5 Verifying and Testing the Logic Tree
50(9)
4.5.1 Verifications
50(1)
4.5.1.1 Parts
51(1)
4.5.1.2 Position
51(1)
4.5.1.3 People
52(1)
4.5.1.4 Paper
52(1)
4.5.1.5 Paradigms
52(1)
4.5.2 Documenting Verifications
53(1)
4.5.3 Strength of the Evidence
54(1)
4.5.4 Confidence Levels
55(2)
4.5.5 Chain of Causation
57(1)
4.5.6 Exercise 4: Logic Tree
57(2)
4.6 Latent Roots versus Contributing Factors
59(1)
4.7 Telling the Story
59(1)
4.8 Summary
60(1)
4.9 Questions to Consider
60(1)
Chapter 5 Effective Action Plans
61(12)
5.1 The Reality of Most RCA Action Plans
61(1)
5.2 A New and Novel Approach to RCA Action Planning
61(3)
5.3 Elements of the Action Plan
64(1)
5.4 Rigor Testing
65(1)
5.5 Action Plan Template
65(2)
5.5.1 Action Plan Metrics
67(1)
5.6 Improvement Tools
67(4)
5.6.1 Standardized Work
67(2)
5.6.2 Training Matrix
69(1)
5.6.3 Process Observation
69(1)
5.6.4 Abnormality Tracker
69(1)
5.6.5 Rounding
70(1)
5.7 Summary
71(1)
5.8 Questions to Consider
71(2)
Chapter 6 RCA Facilitation
73(10)
6.1 Ethics of Inquiry
73(1)
6.2 Practical Aspects for Facilitation
73(5)
6.2.1 Paper Based or Software
73(1)
6.2.2 Skill Development
74(1)
6.2.3 Shared Facilitation
75(1)
6.2.4 Team Focus
75(1)
6.2.5 Active Facilitation
76(1)
6.2.6 Facilitating the Logic Tree
77(1)
6.3 Summary
78(1)
6.4 Questions to Consider
79(1)
6.5 Exercise 5: Logic Tree 2
79(4)
PART II Root Cause Analysis Champions
Chapter 7 RCA Standardized Work by Role
83(6)
7.1 Standardized Work by Role
83(3)
7.1.1 Executive Sponsor
83(1)
7.1.2 Process Owner
84(1)
7.1.3 Direct Caregiver
84(1)
7.1.4 Physician Leader
85(1)
7.1.5 Subject Matter Experts
85(1)
7.1.6 Support Services
85(1)
7.2 Implementing Standardized Work
86(1)
7.3 Summary
87(1)
7.4 Questions to Consider
87(2)
Chapter 8 Barriers to RCA and Their Countermeasures
89(10)
8.1 How Could RCAs Fail?
89(3)
8.2 Countermeasures
92(4)
8.2.1 RCA Facilitation
93(1)
8.2.2 Executive Sponsors
94(1)
8.2.3 Organization
94(1)
8.2.4 RCA Evaluation Tool
94(2)
8.3 Summary
96(1)
8.4 Questions to Consider
97(2)
Chapter 9 Strategies for No Repeat Events
99(8)
9.1 Repeat Events Defined
99(2)
9.2 Strategies for No Repeat Events
101(4)
9.2.1 Review of Action Plans within the Department/Unit
101(1)
9.2.2 Review of Mode Categories across the Organization
101(1)
9.2.2.1 Trending at the Event Level
101(1)
9.2.2.2 Trending at the Mode Level
101(1)
9.2.2.3 Trending at the Latent Root Cause Level
102(1)
9.2.2.4 Spreading Action Plans
103(1)
9.2.3 Systems Reliability
104(1)
9.3 Summary
105(2)
Chapter 10 Teaching RCA
107(10)
10.1 Training Pre-Work
108(1)
10.2 Training Guide
108(9)
10.2.1 Training Outline
109(1)
10.2.1.1 Day 1
109(2)
10.2.1.2 Day 2
111(2)
10.2.2 Teacher's Guide
113(1)
10.2.2.1 Training Exercise #1
113(1)
10.2.2.2 Training Exercise #2
113(1)
10.2.2.3 Training Exercise #3
114(1)
10.2.2.4 Student Handout Training Exercise #1: Train Derailment
114(1)
10.2.2.5 Student Handout Training Exercise #2: Canceled Surgery
114(3)
References 117(2)
Appendix 1 Logic Tree for Train Derailment Exercise 119(2)
Appendix 2 Logic Tree for Canceled Surgery Exercise 121(2)
Index 123
David Allison, CPPS, has 15+ years of facilitating RCA teams, and teaching RCA methodology for patient safety and risk management professionals. He has over 30 years of experience in healthcare and has provided leadership in behavioral health, risk management, and patient safety settings. David has been the process owner for the safety value stream across a healthcare system, helping to reduce the rate of serious safety events with tools such as RCA.

Harold Peters, P.Eng., is an improvement professional with extensive experience in healthcare, service, government, and manufacturing. During his 15+ years in healthcare, he led Lean project and transformation work, facilitated RCAs, and introduced other improvement methodologies like Work Simplification, Theory of Constraints, and Operations Research. In system leadership roles, he established and led the process improvement strategy, structure, standards, and resources for two large healthcare systems across multiple states, and led the system patient safety department in one of the organizations, developing strategy, structure, standards, and teaching RCA methodologies.