Critical Event Review (Root Cause Analysis)

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Critical Event Review(Root Cause Analysis)

• Hutchinson Area
• Health Care
• December 2008

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What are we going to cover?

• What is Critical Event Review (CER)?
• Brief Overview
• Reasons for conducting a Critical Event Review
• Hutchinson Area Health Cares use in
• Long Term Care - Process
• Story

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What is a Critical Event Review?

• A process that uses a systems approach for
  identifying the basic causes for an undesirable
  event or problem
• Focus on the process and systems, not
  individuals
• Uses the technique of asking the why question
  multiple times
• A confidential process

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Reasons to do a Critical Event Review

• It is a review process used to uncover the facts
  and the underlying story that led up to the event
• Identification of contributing factors
• More in-depth understanding of the sequence of
  events
• Assists in improving facility systems/processes
• Promotes proactive Action Plan development to
  assist in preventing recurrence
• Resident Safety
• Reduce the harm to residents by increasing the
  resilience of our responses when the event
  repeats

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Events where use of CER could be considered

• Events with serious outcome for the resident
• Repeating incidents
• Near Misses/Good Catches
• Examples
• Falls
• Medication Errors
• Plan of Care not followed

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CER Selection Criteria

• Initially Joint Commission driven
• Sentinel event standard requiring RCAs to be
  done
• Was applied to CMS sentinel event criteria
• Based on event data analysis
• Highest event (falls)
• Severity
• Resident safety focus reduction of harm
• Future working to be proactive near miss

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Immediate Actions

• Ensure resident and staff are safe
• Notification of Administration
• Assess need for additional resources
• Secure equipment, tubing, medications, involved
  in event
• Communication to resident and family

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Immediate Actions (continued)

• Complete documentation by the care provider
• Medical Record Facts- Objective
  data/description of event
• Event/Incident Report
• Institute an immediate corrective action if
  possible
• Staff Notes (not part of the medical record)
• Coach staff record when resident last seen, what
  they heard, room arrangement, location of
  equipment, your response
• Who, What, When, Where, Why
• Staff notes need to turned into
• Quality Department or Quality Manager
• Drawings/Pictures

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CER Meeting Steps

• Set up initial meeting 48 to 72 hours post event
  (if not sooner)
• Who sets up the meeting
• Identify and invite key players
• Wont compromise resident safety

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Key Players

• Staff from departments/units directly and
  indirectly involved in the event
• Nursing Administration
• Medical Director
• Physician/Provider as needed
• Quality Representative
• Administrator
• Facilitator
• Others as identified

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CER Meeting Steps (continued)

• Coaching Staff
• May be initiated prior to meeting being set up
  if member has not participated before
• Participation in the CER is an opportunity to
  learn
• Chance for staff to tell their story
• Emphasis is on improving the system
• Just in Time Training

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Meeting Preparation

• Room with comfortable atmosphere
• Flip Chart and Markers
• Kleenex
• Coffee/Water/Treats
• Medical Record/Reports
• Any of the pre-work documentation
• Staff Notes
• Chart Review
• Lead nursing completes
• Time line of the event

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Facilitator

• Team training/group skills
• Clinical background can be helpful, but not
  required
• Listening skills use facilitation to uncover
  the story behind the event
• Analytical skills conversational/timeline
  versus investigation data gathering
• Positive sense of humor sensitive deal with
  emotions awareness
• Strong boundaries
• Brings people back to focus
• Ability to manage emotion at the table
  fear/anger
• Is able to identify and draw out people
• Engages the entire team to give their perspective
• Need to support everyones style

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Recorder

• Recorder listen to how they are saying, as well
  as what they are saying
• Facilitator may be the recorder as well
• Would recommend a recorder be available

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Meeting Format

• Introductions and Ground Rules
• Confidentiality
• Titles left at the door - all members need to be
  active participants
• There are no bad questions
• Systems and process focus
• Not blaming/finger pointing
• Want to foster creativity
• You have the solutions
• Brief orientation to CER

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CER Meeting in Progress

• Tell the story
• Brief overview of resident
• Start with the person who found resident
• Try to obtain details of what happened
• What did you see?
• Encourage people to share
• Facilitator stands in front and captures data on
  white flip chart
• BIN list gives credence, but allows
  facilitator to move back to subject
• Try to identify opportunities /gaps as the story
  is presented
• Why, Why, Why?
• How were they laying? Where was the wheel chair?
• What is the purpose having the wheel chair across
  the room?

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Use of Triage Questions

• Helps team understand event
• Assures thoroughness of investigation buckets
• Human factors
• Staffing
• Communication/Information
• Equipment/Environment
• Uncontrollable external factors
• Training
• Rules/Policies/Procedures
• Barriers

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Forms
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CER Meeting cont.

• Identification of factors that may have
  influenced the circumstances that led to the
  event
• Identification of system/process gaps
• Opportunities identified for improvement
• Feedback from participants on how systems can be
  improved is critical
• Is there anything that we could have been done
  differently?
• Development of an action plan based on findings
  with target dates and responsible party listed
• Monitoring/measurement plan as indicated
• (Critical Event Review Corrective Action Plan
  -to be covered more in depth in later
  presentation)
• Follow-up

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Spread the Success/knowledge

• Share with staff and Administration
• Need to go beyond interdisciplinary care team
• Potential
• Share learnings and collaborate with other
  facilities

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Critical Event Review Summary

• To be thorough, a RCA must include
• Determination of human and other factors
• Determine related processes and systems
• Analysis of underlying causes and effects
  series of whys
• Identification of risks and their potential
  contributions

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Questions?
Thank you!