Moving Towards RCA 2 : See One, Do One, Take it Home!

Transcription

1 ML16 The presenters have nothing to disclose Moving Towards RCA 2 : See One, Do One, Take it Home! IHI National Forum Orlando, Florida December 11, 2017 Elizabeth Mort, MD, MPH Brian Cummings, MD; Jana Deen, RN, JD; Merranda Logan, MD, MPH, CPPS; Kayla McEachern, JD

2 Learning Objectives Recognize the importance of the RCA 2 model Learn how to operationalize important RCA2 components, such as immediate post-event action, from huddle to debrief to fact finding Apply the RCA 2 investigational model while enhancing efficiency and developing sustainable improvements Use RCA 2 data collected to identify trends and opportunities for early intervention, and move to a more proactive approach 2

3 Adopting RCA 2 : See One, Do One, Take it Home! Introduction and Overview (20 minutes) Massachusetts General Hospital Edward P. Lawrence Center for Quality & Safety Elizabeth Mort, MD, MPH Senior Vice President, Quality & Safety, Chief Quality Officer 3

4 Mission Guided by the needs of our patients and their families, we aim to deliver the very best health care in a safe, compassionate environment; to advance that care through innovative research and education; and to improve the health and well-being of the diverse communities we serve. 4

5 Original Campus 5

6 Current Campus 6

7 MGH at a Glance ~49,000 Inpatient Admissions/Year 1.5 million Outpatient Visits/Year 100,000 emergency room visits/year More than 42,000 operations/year ~1,046 hospital beds ~$4B total annual revenue ~$3.75B total annual expense 25 satellite locations on hospital license Largest private employer in the city of Boston, more than 30,000 in our workforce 7

8 Massachusetts Environment 8

9 Partners Healthcare, Inc. McLean Hospital North Shore Medical Center - Union North Shore Medical Center - Salem Rehabilitation Hospital Spaulding Rehabilitation Massachusetts General Hospital Nantucket Cottage Hospital Brigham and Women s Martha s Vineyard Hospital Newton-Wellesley Hospital Faulkner Hospital Rehab Hospital of the Cape and Islands Non-Acute Hospital H Acute Care Hospital 9

10 Massachusetts General Physicians Organization 10

11 Key Q&S Committees Drive the Process 1. Quality Oversight Committee reports to Board Quality of Care Committee 2. Quality & Patient Safety Committee reports clinical departments quality indicators through Quality Oversight Committee. Quality & Patient Safety Committee chair sits on Quality Oversight Committee 3. EED Coordinating and Safety Committees report to Quality Oversight Committee

12 GREG PAULY Quality & Safety Steering Committee President of the Hospital CEO of the Physicians Organization Chief Quality & Safety Officer Chief Medical Officer Chief Nursing Officer Medical Director of the Physicians Organization President of the Hospital Dr. Peter Slavin CEO of the Physicians Organization Dr. Timothy Ferris 12

13 MGH Lawrence Center for Quality & Safety Established in 2007 Innovate and keep the Q&S scope ambitious Support the experts Develop a disciplined management approach Data and improvement hub 13

14 Lawrence Center Areas of Expertise Clinical Compliance Risk Management Patient Safety Learning from Errors, Safety Culture Quality Management Analytics and Reporting Process Improvement Affiliate Q&S Advisory Research and Education Partnerships with Patient Care Services, Infection Control, and Clinical Departments

15 Improving Safety: We Promote Learning from Failures NEJM 2010

16 Electronic Safety Reporting Systems

17 We Solicit Proposals for FY 2018 Q&S Goals Disparities Comm. Care Redesign Training Directors PFACs Pharmacy Infection Control ecare Research Affiliates Patient Safety PCS Collab. Gov Performance, Analysis, Improvement PCS Exec Quality & Safety Fellows Ambulatory/ ARMS PTSC Potential Targets Occ. Health Partners Quality & Safety Pt Experience Quality Mgmt HIS Patient Advocacy QA Chairs Exec. WalkRounds Residents/ Fellows CMO Simulation Center Population Health SVP Analytics PCS Quality Program Critical Care Comm. ED/AD PTCL Public Affairs 17

18 We Use a Prioritization Filter : We must cover the basic block focusing on quality, safety and excellence every day Lead the Nation in Quality and Safety Research Leadership: Share our lessons learned. Expand the Q&S knowledge base. Measurement and IT Leadership: Systems Excellence: Influence the design of national metrics. Design measures of distinction. Build IT to support quality measurement. Establish robust Q&S infrastructure. Embed training programs in all hospital departments. Execute on world class safety and quality systems (Medrec, EMAR). Quality, safety and service excellence every day: Establish and sustain a robust culture of patient safety. Excellent care every patient every day Embed Joint Commission safe practices and quality goals in practice every day. 18

19 Just Culture Behaviors and Responses Human Error At-Risk Behavior Reckless Behavior Inadvertent action: slip, lapse, mistake A choice: risk not recognized or believed justified Conscious disregard of unreasonable risk Manage through changes in: Processes Procedures Training Design Manage through: Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness Manage through: Remedial action Punitive action Console Coach Remediate 19

20 Process Improvement Skills are Critical MGH invested in GE Lean training Partners Clinical Process Improvement Program (CPIP) Surveillance for new methods Challenges are, scale and spread 20

21 Develop Peer Expertise in Handling Disruptive Behavior to Promote Professionalism and Safety Cameron D Wright, M.D. Department Quality Chair, Surgery Keith Perleberg, R.N. Former Director PCS Quality & Safety 21

22 Quality Chairs Enable Improvement Each clinical service has a named physician Up to 50% effort protected time Respond to adverse events Advance Q&S improvement Leadership and Training Many physicians have nursing partners in this work 22

23 Advance High Reliability Capability of the Institution 23

24 Adopting RCA 2 : See One, Do One, Take it Home! RCA 2 Overview and Evolution (20 minutes) What s new in RCA 2 RCA 2 at MGH Development of our RCA2 Flow Map Jana Deen, RN, JD Senior Director, Patient Safety 24

25 What s New in RCA 2 Released June 2015 by NPSF Updated January 2016 Emphasizes 3 main points: Be prompt and punctual Identify true contributing factors Make your action plans effective 25

26 MGH Root Cause Analysis Timeline Root Cause Analysis (RCA) established as the methodology required for analysis of adverse events by The Joint Commission (TJC). CQS Patient Safety Team Retreat for gap analysis between current process and RCA2 April 1998 Jan Sept Present Implementation June 2015/ Jan Sept RCA2: Improving Root Cause Analyses and Actions to Prevent Harm Report issued by the National Patient Safety Foundation (NPSF) CQS hosts Essential Skills for Quality Leaders and RCA2 is introduced and taught

27 RCA 2 - Focus on Timeliness Immediate Actions Care for the patient, make the situation safe and sequester equipment Within 72 hours Identify RCA 2 core team, begin fact finding, developing causal statements and identifying solutions Within 30 days and beyond Implement, measure and give/get feedback 27

28 MGH RCA 2 Adaptation 28

29 RCA 2 Core Team RCA 2 Core Team Members Quality chairs/leaders Safety specialist (RCA expert) Subject matter experts Frontline staff not familiar with the event Patient representative/advocate How to make Core Team meetings most effective: Come to the meeting having done the fact-finding and interviewing Prepare/review timeline Focus on creating fishbone diagrams and causal statements Focus on identifying solutions and corrective actions 29

30 RCA 2 - Identify True Causal Factors Use RCA tools to facilitate your investigation Swiss Cheese Model Fishbone Diagram 30

31 RCA 2 - Identify True Causal Factors, cont. Use RCA tools to facilitate your investigation Process mapping 5 Whys 31

32 RCA 2 - Identify True Causal Factors: 5 Rules of Causation Clearly show the cause & effect relationship Contributing factor Causal Statement Use specific & accurate descriptions, rather than negative & vague Human errors must have a preceding cause The manual is poorly written. The pump user manual has 8 point front & no illustrations; as a result nursing staff rarely used it, increasing the likelihood that the pump would be programmed incorrectly. Violations of procedure are not root causes, but must have a preceding cause Failure to act is only causal when there is a pre-existing duty to act The resident selected the wrong dose, which led to the patient being overdosed. Drugs in the computerized POE entry system are given to the user without sufficient space between the different doses on the screen, increasing the likelihood that the wrong dose could be selected, which led to the patient being overdosed. 32

33 RCA 2 Develop Effective Action Plans Action Hierarchy Architectural/physical plant changes New devices with usability testing Engineering controls with forcing functions Do Simplify not process depend on staff to Standardization Tangible involvement by leadership remember to do the right thing Stronger Actions Redundancy Increase in staffing/decrease in workload Software enhancements /modifications Eliminate/reduce distractions Education with simulation-based training Checklists/cognitive aids remember Standardized communication tools Somewhat dependent on staff remembering to do the right thing, but provide tools to help staff to Double checks Depend on caregivers to Warnings remember New procedure/memorandum/policy training or what Training is written in policy Intermediate Actions Weaker Actions 33

34 Conducting an RCA: A Balancing Act Gathering facts while supporting those involved Staff, patients and families Use all available resources: interviews, medical record Defining causes and related opportunities for improvement Single vs. multifactorial (narrow vs. broad focus) Priority, payoff, effort and feasibility Meeting regulatory requirements while promoting learning Timeliness and resources for appropriate thought, response and action 34

35 External Reporting Obligations Department of Public Health (DPH) Board of Registration in Medicine (BORIM) Joint Commission (TJC) Food and Drug Administration (FDA)/MedSun Radiation Control Centers for Medicare & Medicaid Services (CMS) Department of Mental Health (DMH) Payers/Insurance Companies 35

36 Adopting RCA 2 : See One, Do One, Take it Home! Teaching RCA 2 (90 minutes) Fact finding/establishing a timeline Fishbone diagramming as a core team Developing an Action Plan as a core team Merranda Logan, MD, MPH, CPPS Assistant Chief Quality Officer 36

37 RCA 2 Simulation: Agenda Immediate response to an adverse event 5 min Table exercises Fact finding/establishing a timeline 20 min Fishbone diagramming 20 min Action Plan development 20 min Quick debriefs Between table exercises we will reconvene 10 min as a larger group to debrief exercises and identify barriers to implementation 37

38 An Event Has Occurred A 86 year old male with past medical history notable for moderate dementia, essential hypertension and metastatic prostate cancer on chemotherapy presented to the ED with fever and a cutaneous abscess. After being admitted to the inpatient ward, he received a ten fold overdose of morphine, a medication he was allergic to. The patient experienced respiratory depression and angioedema that required Rapid Response. The patient was intubated and transferred to the ICU, but now is alert and oriented. Before knowing any details of the case, what immediate actions/questions come to mind? **Fictitious case for teaching purposes** 38

39 Immediate Response to an Adverse Event Is the patient safe? Are other patients safe? Is the patient being cared for? Has the manager/supervisor been informed? What equipment needs to be sequestered? Is the patient/family being communicated to? Are staff involved being supported/need time off? Has a safety report been filed? Who needs to be interviewed? 39

40 Group Exercise #1 (Intro) Fact finding and establishing a timeline 30 minutes 40

41 Group Exercise #1 (Details) Your facilitator will provide each of you with an assigned role in the event After reviewing the case description and your role description: Take 20 minutes to perform a multidisciplinary event debrief Take 10 minutes for report-out and discussion 20 min Countdown Timer 10 min Countdown Timer 41

42 Group Exercise #1 (Quick Debrief) Core Concepts Immediate Response to an Adverse Event Fact finding and establishing a timeline Report out: Jana and Brian All Triggering Questions (found in Appendix 2 of RCA2) Communication Was information from various patient assessments shared and used by members of the treatment team on a timely basis? Did existing documentation provide a clear picture of the work-up, the treatment plan, and the patient s response to treatment? (e.g., Assessments, consultations, orders, progress notes, medication administration record, x-ray, labs, etc.) Was the correct technical information adequately communicated 24 hours/day to the people who needed it? Was communication between management/supervisors and front-line staff adequate? (i.e., Accurate, complete, unambiguous, using standard vocabulary and no jargon) Training Was the training adequate? If not, consider the following factors: supervisory responsibility, procedure omission, flawed training, and flawed rules/policy/procedure. Fatigue/Schedule Were environmental stressors properly anticipated? Was the environment free of distractions? Was there sufficient staff on-hand for the workload at the time? (i.e., Workload too high, too low, or wrong mix of staff.) Environment/Equipment Was the work area/environment designed to support the function it was being used for? Did the work area/environment meet current codes, specifications, and regulations? Was the equipment designed to properly accomplish its intended purpose? If there was a maintenance program, did the most recent previous inspections indicate that the equipment was working properly? Were personnel trained appropriately to operate the equipment involved Policy/Procedure Was there an overall management plan for addressing risk and assigning responsibility for risk? Had a previous investigation been done for a similar event, were the causes identified, and were effective interventions developed and implemented on a timely basis? Were all staff involved oriented to the job, department, and facility policies regarding: safety, security, hazardous material management, emergency preparedness, life safety management, medical equipment and utilities management? Were there written up-to-date policies and procedures that addressed the work processes related to the adverse event or close call? Barriers What barriers and controls were involved in this adverse event or near miss? 42 Were these barriers designed to protect patients, staff, equipment, or the environment? Was the concept of fault tolerance applied in the system design?

43 Group Exercise #2 (Intro) Fishbone diagramming 30 minutes 43

44 Fishbone Diagram Basic concept first used in the 1920 s by the manufacturing industry Popularized in the 1968 by Kaoru Ishikawa Structured approach to brainstorming causes of a problem 44

45 Fishbone Diagram, cont. Patient factors: Clinical condition Physical factors Social factors Psychological/ mental factors Interpersonal relationships Individual (staff/human) factors: Physical issues Psychological Social/domestic Personality Cognitive factors Task factors: Guidelines/ procedures/ protocols Decision aids Task design Communication factors: Verbal Written Non-verbal Management Team factors: Role congruence Leadership Support + cultural factors Medication Error Education + Training Factors: Competence Supervision Availability / Accessibility Appropriateness Equipment + resources: Displays Integrity Positioning Usability IT/EMR Working condition factors: Administrative Design of physical environment Environment Staffing Workload and hours Time Organisational + strategic factors: Organisational structure Priorities Externally imported risks Safety culture 45

46 Group Exercise #2 (Details) Your folders contain an RCA 2 Simulation Workbook. Pages 2-6 include a summary of the case, a timeline and a blank fishbone diagram As a table, take 20 minutes to complete a fishbone diagram Take 10 minutes for report-out and discussion 20 min Countdown Timer 10 min Countdown Timer 46

47 Group Exercise #2 (Quick Debrief) Core Concepts Fishbone Diagramming Report out: Jana and Brian All 47

48 Group Exercise #3 (Intro) Action plan and measurement 48

49 RCA 2 - Identify True Causal Factors: 5 Rules of Causation Contributing factor Clearly show the cause & effect relationship Causal Statement The wrong concentration of morphine was delivered Use specific & accurate descriptions, rather than negative & vague Human errors must have a preceding cause Violations of procedure are not root causes, but must have a preceding cause The hospital s formulary includes 4 concentrations of morphine which are stored in adjacent identical bins in the pharmacy. The labels on the bins and the medication bags are printed in the same size and color, and are difficult to read due to small and faded font. Pharmacists can be interrupted mid-task. These factors all increase the likelihood that the wrong concentration of morphine could be delivered, which led to the patient s overdose. Failure to act is only causal when there is a pre-existing duty to act 49

50 RCA 2 Develop Effective Action Plans Action Hierarchy Architectural/physical plant changes New devices with usability testing Engineering controls with forcing functions Simplify process Standardization Tangible involvement by leadership Stronger Actions Redundancy Increase in staffing/decrease in workload Software enhancements /modifications Eliminate/reduce distractions Education with simulation-based training Checklists/cognitive aids Standardized communication tools Double checks Warnings New procedure/memorandum/policy Training Intermediate Actions Weaker Actions 50

51 Group Exercise #3 (Details) Your workbook contains a Cause, Action, Process/Outcome measure table. Complete the table for the causal statement provided. As a table, take 20 minutes to develop 3 actions (strong, intermediate, weak). Recommended Action Action Type/Strength Due date Completion date Owner Process/Outcome measure: Date measured: Compliance: Responsible person: 51

52 Group Exercise #3 (Quick Debrief) Core Concepts Action plan development Report out: Jana and Brian All 52

53 Adopting RCA 2 : See One, Do One, Take it Home! RCA 2 Outcomes and Improvement (20 minutes) Local level Hospital level Brian Cummings, MD Associate Chief Quality Officer 53

54 RCA 2 Develop Effective Action Plans Action Hierarchy Architectural/physical plant changes New devices with usability testing Engineering controls with forcing functions Does Simplify not process depend on staff to Standardization Tangible involvement by leadership remember to do the right thing Stronger Actions Redundancy Increase in staffing/decrease in workload Software enhancements /modifications Eliminate/reduce distractions Education with simulation-based training Checklists/cognitive aids remember Standardized communication tools Somewhat dependent on staff remembering to do the right thing, but provide tools to help staff to Double checks Depend on caregivers to Warnings remember New procedure/memorandum/policy training or what Training is written in policy Intermediate Actions Weaker Actions May be critically important- Foundational but not sufficient in isolation 54

55 RCA 2 Know Your Outcomes and Effectiveness Measure Individual RCA 2 Outcomes Develop process and/or outcome measures for each action item Monitor performance on measures Track completion date Audit periodically to ensure sustained improvement 55

56 Effectiveness and Sustainability of the RCA 2 Process Key RCA 2 Metrics: Percentage of RCA 2 reviews with at least one strong or immediate strength action Percentage of actions completed and percentage completed on time Audits or independent checks to verify that hazard mitigation has sustained over time Survey staff and patient satisfaction with the RCA 2 review process Review responses to AHRQ survey questions pertinent to RCA 2 56

57 Warning Signs of an Ineffective RCA 2 One or more individuals are identified as causing the event; causal factors point to human error or blame No stronger or intermediate strength actions are identified Actions do not have completion dates or meaningful process and outcome measures There is little confidence that implementing and sustaining corrective action will significantly reduce the risk of future occurrences of similar events 57

58 RCA 2 Implementation at MGH 1. What are we trying to accomplish? Adopt RCA 2 into our SOP (Standard Operating Procedure) 2. How will we know a change is an improvement? Stronger actions: % of intermediate or strong interventions TIMELY: % RCAs complete under 45 days STRONGER: % of STRONG Actions from RCAs EFFECTIVE: # RCA repeats decrease Near Miss RCAs: % of Non-reportable events with RCAs 3. What changes could we make that might result in improvement Standardize RCA steps- timeliness Utilize taxonomy of RCA causes and actions- Strength Design a clear process for action and follow-up Add near miss cases to mix

59 Getting to Action in Operations: PDSAs in Action! Phase Start Reassessed Date Goal met/change 1. Analysis and Planning Jan 2016 July 2016 Opportunities identified Proceed with didactic and simulations 2. Formal Didactic and Simulation 3. Incremental rollout: cases, education at QPSC. Monitor timeliness from event to completion 4. Further standardize root cause identification and taxonomy 5. Action plan process review Mar 2016 Sept 2016 Introduced and taught to Quality leaders Jan 2017 July 2017 Satisfied with performance, time frames Jan 2017 Fall 2017 July, Oct 2017 December Near Misses/ B casesincorporate Oct 2017 December into RCA Continued work on debrief versus SME meetings RCA contributors and Strengths of actions improving Report of strength of action to QPSC Tracking of all ongoing actions and closed loop of completion (Adopt/Adapt/Abandon) 5 cases presented to date

60 Outcomes: Strength of Action Tracking Year Cases % Cases with a Strong or Intermediate Action Actions % % 2017 to date 33 90% 89 70% % all actions Strong/ Intermediate

61 Closing Thoughts We ve been conducting RCAs for many years at MGH RCA 2 emphasizes three ways to make RCAs more effective: Immediate debriefs Using RCA 2 tools as an RCA 2 core team to identify true contributing factors Action plan and measuring outcomes We have taken a robust RCA process and have achieved even further standardization and improvement and continue to learn along the way 61

62 Did We Achieve Our Goals? Recognize the importance of the RCA 2 model Learn how to operationalize important RCA2 components, such as immediate post-event action, from huddle to debrief to fact finding Apply the RCA 2 investigational model while enhancing efficiency and developing sustainable improvements Use RCA 2 data collected to identify trends and opportunities for early intervention, and move to a more proactive approach 62

63 Open Forum and Sticky Notes Using the sticky notes at your table, identify: 1. One thing you do well in your current RCA process 2. One way you can improve your current RCA process 3. One thing you learned today that you will incorporate into future RCA 2 63

64 Appendix 64