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

Cover
Half Title
Title
Copyright
Contents
Preface
Acknowledgments
Authors
Part I Building an Understanding of RCA
	Chapter 1 The Need for Root Cause Analysis (RCA)
		1.1 Why Investigate Healthcare Unintended Events?
		1.2 Caring for Caregivers
		1.3 Systems Approach
			1.3.1 Aviation’s Breakthrough
		1.4 Leadership Support for a Culture of Safety
			1.4.1 Leadership Responsibility for RCA
		1.5 Patients at the Center
		1.6 Questions to Consider
	Chapter 2 Forms of Analysis
		2.1 Troubleshooting
		2.2 Simple Problem-Solving
		2.3 Complex Problem-Solving
		2.4 A3 Thinking
		2.5 Whys
		2.6 Failure Modes and Effects Analysis
		2.7 Case Quality Review
		2.8 Apparent-Cause Analysis
		2.9 Logic Tree
		2.10 Meta-Analysis
		2.11 Peer Review
		2.12 Morbidity and Mortality Conference
		2.13 Summary of the Different Forms
		2.14 Selecting the Form of Analysis
		2.15 Forms of RCA
			2.15.1 Telephone Cutover Disaster: A Case Study
			2.15.2 5 Whys, Fishbone, and Bimodal Methods
		2.16 Questions to Consider
	Chapter 3 Pre-Work for an RCA Team Meeting
		3.1 Early Investigation and Preservation of Evidence
		3.2 Tasks in Preparation
			3.2.1 Defining Serious Safety Events
			3.2.2 Ordering the Team
			3.2.3 The Chronology
			3.2.4 The Logic Tree Top Box
			3.2.5 Top Boxes with Two Modes
			3.2.6 Logistics
		3.3 Exercise 1: Chronology
		3.4 Summary
		3.5 Questions to Consider
	Chapter 4 Creating the Logic Tree
		4.1 Logic Tree Root Causes
			4.1.1 Exercise 2: Types of Roots
		4.2 Logic Tree Hypothesizing
			4.2.1 Hypotheses
			4.2.2 How Could versus Why
			4.2.3 Two Approaches to Hypothesizing
			4.2.4 Boolean Logic
		4.3 Risks Associated with Hypothesizing
			4.3.1 Categories versus Hypotheses
				4.3.1.1 Countermeasure
			4.3.2 Latent Roots as Hypotheses
				4.3.2.1 Countermeasure
			4.3.3 Hypotheses Are Too Broad
				4.3.3.1 Countermeasure
			4.3.4 Hypotheses Are Too Narrow
				4.3.4.1 Countermeasure
		4.4 The Importance of Facilitating Hypothesizing
			4.4.1 Exercise 3: Hypothesis Generation
		4.5 Verifying and Testing the Logic Tree
			4.5.1 Verifications
				4.5.1.1 Parts
				4.5.1.2 Position
				4.5.1.3 People
				4.5.1.4 Paper
				4.5.1.5 Paradigms
			4.5.2 Documenting Verifications
			4.5.3 Strength of the Evidence
			4.5.4 Confidence Levels
			4.5.5 Chain of Causation
			4.5.6 Exercise 4: Logic Tree
		4.6 Latent Roots versus Contributing Factors
		4.7 Telling the Story
		4.8 Summary
		4.9 Questions to Consider
	Chapter 5 Effective Action Plans
		5.1 The Reality of Most RCA Action Plans
		5.2 A New and Novel Approach to RCA Action Planning
		5.3 Elements of the Action Plan
		5.4 Rigor Testing
		5.5 Action Plan Template
			5.5.1 Action Plan Metrics
		5.6 Improvement Tools
			5.6.1 Standardized Work
			5.6.2 Training Matrix
			5.6.3 Process Observation
			5.6.4 Abnormality Tracker
			5.6.5 Rounding
		5.7 Summary
		5.8 Questions to Consider
	Chapter 6 RCA Facilitation
		6.1 Ethics of Inquiry
		6.2 Practical Aspects for Facilitation
			6.2.1 Paper Based or Software
			6.2.2 Skill Development
			6.2.3 Shared Facilitation
			6.2.4 Team Focus
			6.2.5 Active Facilitation
			6.2.6 Facilitating the Logic Tree
		6.3 Summary
		6.4 Questions to Consider
		6.5 Exercise 5: Logic Tree 2
Part II Root Cause Analysis Champions
	Chapter 7 RCA Standardized Work by Role
		7.1 Standardized Work by Role
			7.1.1 Executive Sponsor
			7.1.2 Process Owner
			7.1.3 Direct Caregiver
			7.1.4 Physician Leader
			7.1.5 Subject Matter Experts
			7.1.6 Support Services
		7.2 Implementing Standardized Work
		7.3 Summary
		7.4 Questions to Consider
	Chapter 8 Barriers to RCA and Their Countermeasures
		8.1 How Could RCAs Fail?
		8.2 Countermeasures
			8.2.1 RCA Facilitation
			8.2.2 Executive Sponsors
			8.2.3 Organization
			8.2.4 RCA Evaluation Tool
		8.3 Summary
		8.4 Questions to Consider
	Chapter 9 Strategies for No Repeat Events
		9.1 Repeat Events Defined
		9.2 Strategies for No Repeat Events
			9.2.1 Review of Action Plans within the Department/Unit
			9.2.2 Review of Mode Categories across the Organization
				9.2.2.1 Trending at the Event Level
				9.2.2.2 Trending at the Mode Level
				9.2.2.3 Trending at the Latent Root Cause Level
				9.2.2.4 Spreading Action Plans
			9.2.3 Systems Reliability
		9.3 Summary
	Chapter 10 Teaching RCA
		10.1 Training Pre-Work
		10.2 Training Guide
			10.2.1 Training Outline
				10.2.1.1 Day 1
				10.2.1.2 Day 2
			10.2.2 Teacher’s Guide
				10.2.2.1 Training Exercise #1
				10.2.2.2 Training Exercise #2
				10.2.2.3 Training Exercise #3
				10.2.2.4 Student Handout Training Exercise #1: Train Derailment
				10.2.2.5 Student Handout Training Exercise #2: Canceled Surgery
References
Appendix 1: Logic Tree for Train Derailment Exercise
Appendix 2: Logic Tree for Canceled Surgery Exercise
Index