Root cause analysis and improvement in the healthcare sector : a step-by-step guide

256 Pages·2009·5.348 MB·English

by  Bjørn Andersen, Tom Fagerhaug, and Marti Beltz

Root Cause Analysis
and Improvement in
the Healthcare Sector
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Root Cause Analysis
and Improvement in
the Healthcare Sector
A Step-by-Step Guide
Bjørn Andersen, Tom Fagerhaug, and Marti Beltz
ASQ Quality Press
Milwaukee, Wisconsin
American Society for Quality, Quality Press, Milwaukee 53203
© 2010 by ASQ
All rights reserved. Published 2009
Printed in the United States of America
15 14 13 12 11 10 09 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Andersen, Bjørn.
Root cause analysis and improvement in the healthcare sector : a step-by-step guide / Bjørn Andersen,
Tom Fagerhaug, and Marti Beltz.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-87389-780-8 (ring bound : alk. paper)
1. Medical errors—Prevention. 2. Medical care—Quality control. I. Fagerhaug, Tom, 1968–
II. Beltz, Marti. III. Title. [DNLM: 1. Quality of Health Care. 2. Health Facilities—organizations
& administration. 3. Systems Analysis. W 84.41 A544r 2010]

R729.8.A53 2010
610.28'9—dc22 2009052472
ISBN: 978-0-87389-780-8
No part of this book may be reproduced in any form or by any means, electronic, mechanical, photocopying,
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Table of Contents
CD-ROM Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
List of Acronyms  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Chapter 1 Root Cause Analysis in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
All Organizations Have Problems—Why Is RCA So Important in Healthcare?..... 2
Brief History of RCA in Healthcare ...................................... 3
Definition of a Problem ................................................ 5
Different Levels of Causes.............................................. 6
The Nature of Variation................................................ 7
Root Cause Analysis .................................................. 8
Related Tools, Processes, and Systems .................................... 9
System-Level Impediments to Effective RCAs .............................. 10
Person-Level Impediments to Effective RCAs............................... 11
Practice-Level Impediments to Effective RCAs ............................. 12
Chapter 2 The Root Cause Analysis Process  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
The Root Cause Analysis Process ........................................ 14
Explanation of the Table ............................................... 16
Examples ........................................................... 17
Full Process Case Introduction .......................................... 20
Chapter 3 Step 1: Define the Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Purpose of Step 1: Define the Event ...................................... 22
Substeps in Step 1: Define the Event...................................... 23
1a: Trigger the RCA Process ............................................ 24
1b: Mandate and Organize the RCA Team ................................. 25
1c: Plan the RCA Project............................................... 26
v
vi Table of Contents
Gantt Chart ......................................................... 27
1d: Describe the Event in Detail ...................................... ... 28
Eliminate Bias ....................................................... 29
Interview ........................................................... 30
Survey .... ............ ............................................. 31
Checklist for Step 1: Define the Event..................................... 32
RFO Case Step 1: Define the Event....................................... 33
Project Planning...................................................... 35
Defining the Event.................................................... 36
Chapter 4 Step 2: Find Causes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Purpose of Step 2: Find Causes.......................................... 38
Substeps in Step 2: Find Causes ...... ................................... 39
2a: Process Mapping .................................................. 40
Flowchart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Flowchart Example ................................................... 42
2b: High-Level Mapping ............................................... 43
Contextual and Environmental Factors .................................... 44
2c: Brainstorming of Possible Causes .. ................................... 45
Fishbone Chart....................................................... 46
Example Fishbone Chart ............................................... 47
Checklist for Step 2: Find Causes ..................................... ... 48
RFO Case Step 2: Find Causes .......................................... 49
High-Level Mapping .................................................. 51
Identifying Possible Causes .......................................... ... 52
Chapter 5 Step 3: Find the Root Cause  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Purpose of Step 3: Find the Root Cause ................................... 54
Substeps in Step 3: Find the Root Cause................................... 55
3a: Categorizing Possible Causes......................................... 56
Possible Cause Category Examples ....................................... 57
3b: Constructing a Cause-and-Event Tree .................................. 58
Example Cause-and-Event Tree.......................................... 59
3c: Analyze Possible Causes to Find the Root Cause ......................... 60
Five Whys .......................................................... 61
Example Five Whys................................................... 62
Fault Tree........................................................... 63
Example Fault Tree ................................................... 64
Problem Concentration Diagram ......................................... 65
Example Problem Concentration Diagram.................................. 66
Span of Control Analysis............................................... 67
3d: Collate the Findings................................................ 68
Example Collate the Findings ........................................... 69
Table of Contents vii
Checklist for Step 3: Find the Root Cause.................................. 70
RFO Case Step 3: Find the Root Cause.................................... 71
Cause-and-Event Tree ................................................. 72
Five Whys to Find Root Cause .......................................... 73
Collating the Findings .............. ................................... 74
Chapter 6 Step 4: Find Solution(s)  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Purpose of Step 4: Find Solution(s)....................................... 76
Substeps in Step 4: Find Solution(s) ...................................... 77
4a: Explore the Root Cause .......................................... ... 78
Exploration of the Root Cause in Practice.................................. 79
4b: Identify Solution(s) ............................................. ... 80
Benchmarking ................................ ....................... 81
Using Benchmarking .................................................. 82
4c: Specify/Describe the Solution(s)...................................... 83
Checklist for Step 4: Find Solution(s) ..................................... 84
RFO Case Step 4: Find Solution(s) ....................................... 85
Benchmarking for Solutions............................................. 86
Describing the Solutions ............................................... 87
Chapter 7 Step 5: Take Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Purpose of Step 5: Take Action.......................................... 90
Substeps in Step 5: Take Action.......................................... 91
5a: Analyze the Implementation Setting ................................... 92
Force Field Analysis................................................... 93
Example Force Field Analysis ........................................... 94
5b: Decide on the Implementation Organization............................. 95
5c: Create an Accepted Implementation Plan ............................... 96
Implementation Plan/Project Proposal Sample Structure ...................... 97
5d: Communicate and Create Ownership .................................. 98
5e: Implement the Solution ............................................. 99
Checklist for Step 5: Take Action ........................................ 100
RFO Case Step 5: Implementation Analysis ................................ 101
Deciding on the Implementation Approach................................. 102
Implementation Plan ............................................... ... 103
Creating Awareness ................................................... 104
Chapter 8 Step 6: Measure and Assess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Purpose of Step 6: Measure and Assess ................................ ... 106
Substeps in Step 6: Measure and Assess................................... 107
6a: Conduct a Pilot Study .............................................. 108
6b: Undertake Measurements............................................ 109
Other Usages of Measurements .......................................... 110
viii Table of Contents
Effective and Efficient Measurements..................................... 111
6c: Assess the Effects .............................................. ... 112
6d: Put in Place Safeguards Against Event Reoccurrence...................... 113
6e: Report and Close the RCA Project .................................... 114
Checklist for Step 6: Measure and Assess.................................. 115
RFO Case Step 6: Measure and Assess.................................... 116
Modifying the Solution ................................................ 117
Reporting and Closing the Project........................................ 118
Chapter 9 Advanced Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Advanced and Basic Tools.............................................. 120
Spider Chart......................................................... 121
The Steps in Using a Spider Chart........................................ 122
Example Spider Chart ................................................. 123
Critical Incident ...................................................... 124
Example of Critical Incident ......................................... ... 125
Check Sheet ...................................................... ... 126
Example Check Sheet ................................................. 127
Bottleneck Analysis ................ ................................... 128
Steps in Using Bottleneck Analysis....................................... 129
Example Bottleneck Analysis ........................................... 130
Histogram........................................................... 131
The Steps in Creating a Histogram ....................................... 132
Example Histogram ................................................... 133
Pareto Analysis....................................................... 134
Example Pareto Chart ................................................. 135
Scatter Chart ........................................................ 136
Example Scatter Chart................................................. 137
Performance Matrix................................................... 138
The Steps in Using a Performance Matrix.................................. 139
Example Performance Matrix ........ ................................... 140
Failure Mode and Effects Analysis (FMEA)................................ 141
The Steps in FMEA................................................... 142
Example FMEA Worksheet............................................. 143
Six Thinking Hats .................................................... 144
The Steps in Using Six Thinking Hats .................................... 145
Impact Effort Matrix ............................................... ... 146
Example Impact Effort Matrix........................................... 147
Summary ................................ ........................... 148
Chapter 10 Hardwiring the Use of RCA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Prioritizing Responses and Resource Allocation............................. 150
Increasing the Timeliness of Analysis..................................... 151
Table of Contents ix
Increasing the Strength of Solutions ...................................... 152
Calculating the Business Case........................................... 153
Using Classification Taxonomies......................................... 154
Conducting Meta-Analysis of RCAs ...................................... 155
Publishing Results and Creating Best Practice Toolkits .................... ... 156
Providing Transparency in Tools and Training .............................. 157
Chapter 11 The Future of Root Cause Analysis in Healthcare  . . . . . . . . . . . . . . . . . . 159
What Is Next?........................................................ 160
Advanced Research: Understanding of the Nature of Human Error and
High Reliability Organizations .................. ..................... 161
Creating a Culture of Safety ............................................ 162
Instituting Policy and Process Specifics ................................... 163
Increase in Transparency and Incentives................................... 164
Increased Standardization .............................................. 165
Collection of Best Practice Data ......................................... 166
Increase in Resources and Training....................................... 167
Move to Critique and Increase Accountability ........................... ... 168
Resources  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
A. Templates...................................................... ... 171
RCA Reporting Framework.......................................... 172
RCA Team Mandate ............................................... 174
RCA Team Composition Template .................................... 175
Gantt Chart Template .............................................. 176
Fishbone Chart Template............................................ 177
Five Whys Template ............................................... 178
Force Field Analysis Template ....................................... 179
Spider Chart Template.............................................. 180
Check Sheet Template.............................................. 181
Pareto Chart Template.............................................. 182
Scatter Chart Template ............................................. 183
Performance Matrix Template........................................ 184
FMEA Worksheet Template ......................................... 185
Impact Effort Matrix Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Histogram Template ............................................... 187
B. Guidelines for Evaluating RCAs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
C. Adverse Events ................................................. ... 195
D. Suggested Further Reading........................................... 201
E. Institutions and Organizations......................................... 203
F. RCA Presentation................................................... 209
G. Resource CD...................................................... 227
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