Category: Medical/Healthcare

Welcome Marcus Miller!

July 13th, 2018 by

TapRooT® is growing! We are pleased to welcome Marcus Miller, Vice President of Business Development.

Marcus has hit the ground running, and you may have already read some of his informative healthcare-focused posts on the Root Cause Analysis Blog:

  • Using TapRooT® to Prevent Medicare Payment Reduction (Read post.)
  • QAPI and TapRooT®: The Bridge to Operational Excellence and Quality Care in our Nursing Homes (Read post.)
  • Joint Commission Focuses Surveys to Assess Safety Culture (Read post.)
  • Winners and Losers in Healthcare’s Shift to Value-Based Payments (Read post.)
  • Bias and Blame in Healthcare’s Culture has to Change (Read post.)

We hope you will join us in welcoming him to the TapRooT® team. To learn more about Marcus, click here.

 

 

 

 

Winners and Losers in Healthcare’s Shift to Value-Based Payments

July 9th, 2018 by

 

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The 2010 Affordable Care Act (ACA) was established to shift payment away from the volume of services provided toward the quality of those services. The ACA directed the Department of Health and Human Services to create a budget neutral payment model. CMS (Centers for Medicare & Medicaid Services) published an ACA fact sheet in 2015 that can be found here.

What does budget neutral mean in this case? A very smart healthcare executive explained it to me.  She said that budget neutral means you will have losers and you will have winners. The Department of Heath and Human Services had to put a payment model in place that takes money away from the losers and gives it to the winners so Medicare doesn’t see an increase in costs but still incentivizes providers to focus on quality. If you don’t have positive outcomes, money will be taken away and given to the providers that do show positive outcomes (the winners). So the difference between winners and losers is the quality of their outcomes. TapRooT® should be the quality improvement process healthcare organizations use to ensure they are on the winning side by improving quality and safety which also protects their revenue and margins. To find out more how your organization can improve your outcomes and protect your reimbursement, please contact me at marcus.miller@taproot.com.

Ever have trouble with root cause analysis during batch production with impurities?

July 6th, 2018 by

We received the question below in our TapRooT® Root Cause Analysis Users & Friends Group on LinkedIn, please join the discussion with your experiences and best practices.

How would one do a SnapCharT® for intermittent product quality issues that span weeks/months?

The only way to detect the product impurity is to use the product. Even so, the impurity seems random in the same batch or lot, at different weeks or months, with different upstream raw material suppliers, with different personnel. Past root cause analysis was not systematic enough to find the rc. Fixes did not solve.

Joint Commission Focuses Surveys to Assess Safety Culture

June 26th, 2018 by

 

 

Healthcare is catching up to other industries that have strong continuous improvement programs like mining, gas and oil. Joint Commission is leading that charge by implementing survey process improvements this month for how it assesses the safety culture in hospitals and critical access hospitals.  These improvements will be implemented for all other programs by October of this year. See this article for more details: (Read article.) Continuous Quality Improvement has become a major focus for payers.

In addition, the value-based payment model is replacing the fee for service payment model faster than anticipated. Healthcare organizations must find a comprehensive continuous quality improvement process for patient safety and to strengthen clinical and financial outcomes. Healthcare organizations must protect their revenue by limiting the financial impacts of poor clinical outcomes through a strong continuous quality improvement program. Survival is at stake. Medicare sequestration and payment penalties can easily erase already slim margins.

TapRooT® is that comprehensive continuous quality improvement process that Joint Commission or State Survey teams love to see as part of your QAPI program. TapRoot® trains safety, compliance and quality teams on complete investigation/auditing techniques, finding why incidents occur and identifying the root cause of those mistakes, errors or failures, identifying and implementing corrective actions and ensuring they are effective. TapRooT® has remarkable software that guides teams through the process and helps create impressive reports for management or survey teams.

If you would like to learn more to decide if TapRooT® is the right continuous quality improvement process for your organization, you can contact me at marcus.miller@taproot.com.

 

 

QAPI and TapRooT®: The Bridge to Operational Excellence and Quality Care in our Nursing Homes

June 1st, 2018 by

 

TapRooT® and QAPI

 

The Center for Medicare and Medicaid Services (CMS) defines QAPI as the coordinated application of two mutually reinforcing aspects of quality management systems:  Quality Assurance (QA) and Performance Improvement (PI) = QAPI.  Every nursing home in the U.S. is required to have a well documented QAPI program to be compliant with the Affordable Care Act.  Nursing homes are required to continuously identify and correct quality deficiencies as well as sustain performance improvements.

TapRooT® is used to identify root causes of potential and actual risk to quality performance and prescribes corrective actions that will eliminate the risk or significantly reduce risk and consequences of incidents.  TapRooT® training, tools and software are perfect solutions to implementing and maintaining a strong, compliant QAPI program.   

Let’s first look at the QA portion of QAPI.  QA is defined by CMS as the specification of standards for quality of service and outcomes, and a process throughout the nursing home for assuring that care is maintained at acceptable levels in relation to those standards.  QA is ongoing, both anticipatory and retrospective in it’s efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards.  TapRooT® processes ensure specification of standards by prescribing proven best practices for the root cause of any problem affecting quality of service, outcomes or breakdown of processes that assure  quality of care.  TapRooT® training, tools and software ensure the real root cause is identified by honing the teams’ skill in auditing and investigations practices that meet the criteria for both anticipatory and retrospective efforts in quality assurance. The TapRooT® Corrective Action Helper Guide will lead the team to proven best practices once root causes are identified and ensures the actions are effective. TapRooT®  will also help teams measure and compare current performance against performance standards and goals.

CMS defines PI as the continuous study and improvement of processes with the intent to better services or outcomes, and prevent or decrease the likelihood of problems or barriers to improvement.  TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement training, tools and software will lead QAPI teams through implementation of a continuous improvement program.  There are countless good QAPI teams out there that are great at identifying problems but struggle with prescribing, implementing and measuring the effectiveness of corrective actions.  They typically prescribe the weakest of corrective actions which generally include the “re” actions:

  • Re-train
  • Re-write the procedure or process
  • Re-mind
  • Re-emphasize
  • Re-evaluate
  • Re-view
  • Re-peat warnings, discipline training, etc.

The strongest corrective actions include putting new or additional safeguards in place, or even better, removing the risk or removing the patient from harms way.

Using TapRooT® to identify the real root causes of quality and performance issues through strong audit and investigation techniques and implementing effective corrective actions that lead to continuous improvement will help the QAPI team achieve Operational Excellence.  The big winners are our loved ones who took care of us and now need our commitment to providing them the quality care they deserve.

Want to learn more? You can contact us through the website Taproot.com, call into our office at 865.539.2139 or attend one of our public TapRooT® Courses or contact us to schedule an onsite course.

 

 

Using TapRooT® to Prevent Medicare Payment Reductions

May 30th, 2018 by

 

Medicare has introduced several programs that attempt to link quality of care to payment. That is a tremendous challenge for healthcare providers that are used to the fee-for-service payment model Medicare traditionally used to reimburse providers. For example, in the fee-for-service payment model, healthcare providers bill Medicare for the number of visits and/or tests they order for the patient. If providers did the work and it’s well documented, they could depend on Medicare payment. Medicare is now shifting that fee-for-service payment model to value-based payment models. Healthcare providers will now be reimbursed for providing high quality services, and incur payment reductions for poor patient outcomes.

A couple of examples of Medicare’s value-based purchasing programs are:

  1. Hospital Readmissions Reduction Program. The Affordable Care Act authorizes Medicare to reduce payments to acute care hospitals with excess readmissions for patients who were treated for conditions such as heart attacks, hip and knee replacements, pneumonia, COPD and/or Coronary Artery Bypass Graft Surgery.
  2. Hospital Value-Based Purchasing. Medicare adjusts a portion of payments to hospitals at the beginning of each fiscal year based on how well they perform on each outcome measure compared to all hospitals or how much they improve their own performance during a prior baseline period.
  3. Hospital-Acquired Condition Reduction Program. The Affordable Care Act also authorized Medicare to reduce payments to hospitals that are in the bottom 25% for certain quality outcomes and hospital acquired conditions.

The healthcare industry now more than ever needs to develop its skill in proactively identifying the root causes of preventable hospital readmissions and the root causes for poor quality measures that affect payment. TapRooT® is a solution. TapRooT® software and training teaches us to identify the real root causes of problems (not just the problems) and build and execute corrective actions that can ensure patients have better experiences and performance outcomes while protecting against payment reductions that hurt the bottom line.

I’ll never forget the mantra of a friend of mine who was an executive at a non-for-profit organization: You can’t help the poor if you are the poor. If healthcare providers don’t transition from the fee-for-service payments to valued-based payment models, it won’t take a root cause analysis to see why they failed.

Learn how to use proactively in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. (View schedule of upcoming courses here.)

We hope to see you at the IHI/NPSF Patient Safety Conference!

May 14th, 2018 by

If you plan to attend the 2018 IHI/NPSF Patient Safety Conference in Boston, MA on May 23 -25, stop by and say “hello.” Per Ohstrom, Anne Roberts, and Barb Carr (pictured left to right) will be at Booth #316 in Exhibit Hall C discussing how TapRooT® can help you and answer any questions you might have.

We will be at Booth #316 during these times:

Wednesday: 3:30pm – 5:30pm

Thursday: 12:00pm – 1:30pm & 4:30pm – 6:30pm

Friday: 7:00am – 8:30am

The first 500 visitors will receive a special prize, so do not miss out on your free gift! Stop by early to increase your chances in receiving a prize.

Hope to see you there!

Is Having the Highest Number of Serious Incidents Good or Bad?

March 6th, 2018 by

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I read an interesting article about two hospitals in the UK with the highest number of serious incidents.

On the good side, you want people to report serious incidents. Healthcare has a long history of under-reporting serious incidents (sentinel events).

On the good side, administrators say they do a root cause analysis on these incidents.

On the bad side, the hospitals continue to have these incidents. Shouldn’t the root cause analysis FIX the problems and the number of serious incidents be constantly decreasing and becoming less severe?

Maybe they should be applying advanced root cause analysis?

Are you planning to attend the 20th Annual IHI/NPSF Patient Safety Congress in Boston?

February 20th, 2018 by


Per Ohstrom and I are looking forward to going to Boston, May 23 – 25, for the 20th Annual IHI/NPSF Patient Safety Congress. If you’re attending, please make a note to stop by the Exhibit Hall and visit us in Booth #316.

Healthcare facilities need multiple levels of analysis to truly identify the causes of patient safety related incidents. We’d love to talk to you about how TapRooT® offers robust data gathering tools and consistent objective root cause analysis to help you build the most effective corrective actions that will address and prevent problems. These tools all working in harmony with your systems will create a much safer environment for patient care.

We hope to see you there!

2018 Global TapRooT® Summit Patient Safety Track

February 12th, 2018 by

The Patient Safety Track is for healthcare professionals and those interested in healthcare. Michele Lindsay shares about what you can expect when you register for this informative track.

Register for the Patient Safety Track.

Learn more about the Summit.

What Will You Learn in the Patient Safety Best Practice Track at the Summit?

January 12th, 2018 by

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Since 1994, System Improvements has included information about improving Patient Safety in the Summit. This year we have a whole best Practices Track dedicated to improving patient safety and a Keynote Speaker talking about a fatal sentinel event.

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Let’s start by telling you about Dr,. Carol Gunn, one of our Keynote Speakers. She is a medical doctor who was trained to use the TapRooT® Root Cause Analysis System before she became a doctor. While she was a doctor, her sister died in a hospital from “complications.” It turns out that those complications were a result of a medical error. She will tell the story of her sisters death and what can be learned when root cause analysis is used properly and what happens when sentinel events are covered up.

Now let’s look at what’s covered in the Patient Safety Best Practices Track:

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Improving Patient Safety – Gaining a Win from a Loss (Michel Lindsay): Michele will share the evolution and success of their system for managing patient safety incidents and the expanded role of the Quality of Care Committee (QCC) on its journey to a high reliability organization at Southlake Regional Health Centre. A serious incident can have devastating outcomes to patients, their families, and to the caregivers involved. Even errors that result in no or mild harm to the patient can be devastating and career changing for staff and physicians. We have created structures and supports for immediate and long term organizational learning and improvements from incidents while maintaining a culture of care. Learn how the process QCC role has assisted in removing the shame and blame from an incident and turned it into a powerful lever for caring, sharing and repairing. Michele will describe the investigation processes using illustrations and case studies to describe how patient safety, learning, performance and culture has been positively impacted by their approach. The presentation includes the input from the COO & SVP Operations, Director of Surgery, the Director of Risk, the Manager of Risk, the Manager of a Cardiac Clinical Program, a Physician and the Quality Specialist.

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Improving Sentinel Event Investigations (Ken Turnbull): Ken is one of the authors of the new book, Improving Patient safety with TapRooT® Root Cause Analysis (to be released somewhere around the time of the Summit) and will share some of the new ideas presented in the book.

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Using Wearables to Minimize Daily Human Errors (Kevin McManus): Look at how wearables are being used both now and in the future to help prevent errors and identify problems more effectively.

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Deep Dive Into the Procedures Basic Cause Category (Ralph Brickey): Procedures (checlists) are almost a new concept being used to improve patient safety. Learn from the TapRooT® procedures best practices including: Learn: the philosophy and practice of using procedures; different types of procedures and how they are addressed in the TapRooT® Root Cause Dictionary and the Root Cause Tree®; and two human performance tools to aid in proper procedure use

Influencing Change (Jonathon Kennedy): Change is what improving performance is all about. What is the best way to influence change? Hear what Jonathan Kennedy has to say.

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Top 7 Secrets of a Great Investigation Interview (Barb Carr): Take your interviewing skills to the next level and collect better quality and quantity of information from your investigative interviews by harnessing the power of the seven secrets.
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TapRooT® Users Share Best Practices (Linda Unger): Share best practices about root cause analysis, investigations, and performance improvement with industry leaders from around the world.

Performance Improvement Gap Analysis (Linda Unger): Evaluate where you are and where you want to go and how you will apply what you have learned at the Summit to improve performance at your facility. The goal of this session is to go back to work with a plan to improve patient safety.

That an impressive list of breakout sessions.

So are you really interested in improving patient safety? Then you should attend the 2018 Global TapRoot® Summit. Register HERE!

This is “National Hand Washing Awareness Week”

December 6th, 2017 by

Want to prevent infections? Wash your hands!

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A press release from the Henry the Hand Foundation

National Handwashing Awareness Week Dec 3-9, 2017

In a recent article in New England Journal of Medicine  “Chasing Seasonal Influenza”  it was reported …according to the Australian Government Department of Health. Influenza A (H3N2) viruses predominated, and the preliminary estimate of vaccine effectiveness against influenza A (H3N2) was only 10%. The implications for the Northern Hemisphere are not clear, but it is of note that the vaccine for this upcoming season has the same composition as that used in the Southern Hemisphere.

BUT, No need to worry because in 1999 during first Flu vaccine shortage a community wide coalition created events promoting handwashing with coloring contests throughout schools and community centers and ended during the first National Handwashing Awareness Week! Result was one of the healthiest year for our community!

Poster

Share the National Handwashing Awareness Week poster with everyone you believe could benefit!! And an additional bonus is True Flu Prevention poster for those who do NOT want the flu or flu-like illness!!

Our latest innovation is the first portable self teaching Hand Hygiene Learning Center that helps students train themselves. Sized for Early Childhood age group and one for larger students, as well! Put it outside the Classroom, in the cafeteria, playground or wherever there may a norovirus/shigella outbreak!

There is a Classroom Tool Kit included to help your students sustain the habit! The addition of the Tool Kit can help train your staff, students and their families with the tools to keep them healthy year round by practicing Henry the Hand’s 4 Principles of Hand Awareness.

The BEST science-based, multi sensory curriculum in a Tool Kit that is so easy to understand it teaches itself! Your gift for Global Handwashing Day!!

In the  Science of Habit, Dr Jelena Vujcic discusses the two critical components around habit : first, creating a good habit and second, is sustaining the habit. However, sustaining the habit is the more difficult component to achieve!

Visit the Henry the Hand Website.

What Does a Patient Want After a Medical Error?

November 8th, 2017 by

Of course, a patient would prefer that a medical error NEVER happens. Thus most people want the hospital they attend to have a great performance improvement program that proactively PREVENTS errors from occurring. However, even with the best programs, an error is still possible (even if it is highly unlikely).

A study in the JAMA Internal Medicine says that patient’s and their families want physicians and hospitals to communicate with them to explain what the facility is doing to prevent similar future incidents. We are going to try harder is not enough. They want real root cause analysis with effective corrective actions.

The study said that “Patients and families strongly desired to know what the hospital did to prevent recurrences of the event, but 24 of 30 reported receiving no information about safety improvement efforts.”

So what do patient’s want?

  • Adequate compensation
  • Friendly communication
  • To be heard by the physician and the hospital.
  • How the hospital/physician would prevent future errors

If you don’t have advanced root cause analysis you can’t meet the patient’s expectation.

Maybe it is time to learn about TapRooT® and start your facilities journey to world-class root cause analysis and performance improvement?

More Proof that Hospitals Need to Improve Root Cause Analysis

November 6th, 2017 by

What would you think if your hospital received a “D” in a Leapfrog hospital rating? THIS ARTICLE points out three hospitals in the Atlanta area that received the worst Leapfrog scores.

My response would be that they need better root cause analysis. With advanced root cause analysis they would be finding the causes of infections, treatable complications, unnecessary blood clots, collapsed lungs, air or gas bubbles in the blood, and other preventable errors.

Effective root cause analysis is the basis for an effective performance improvement program. Without effective root cause analysis, a hospital is doomed to repeat their errors because they are guessing at solutions.

Want to find out more about the 5-Day Advanced Root Cause Analysis Training? See:

http://www.taproot.com/courses#5-day-root

The NHS in the UK Provides Guidance on Learning from Deaths

October 24th, 2017 by

Learning from Deaths

What guidance does the document provide? Here’s the table of contents:

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The NHS has also established the Healthcare Safety Investigation Branch (HSIB) to perform independent investigations of unnecessary patient deaths. For more information about the HSIB, see:

https://www.hsib.org.uk/about-us/

Monday Accidents & Lessons Learned: Five People Die After Using Weight Loss Balloons

September 18th, 2017 by

 

According to the Food & Drug Administration’s report, five people have died since 2016 after being treated with weight loss balloon devices. The science behind this technology is that the balloon takes up space in the stomach after being filled with solution and this leaves less room in the stomach for food. The balloon is left in the patient’s stomach for six months while the patient learns to eat differently.

The five deaths occurred within a month of balloon placement.  We know that four of the deaths involved a balloon from the same manufacturer. However, nothing has been found linking the deaths to the medical device. In the TapRooT® System, an investigator would examine an incident like this by first creating a sequence of events. Once the sequence of events is completed,  more information would be collected.  For example:

Did the patient understand the risks?

Was the patient closely monitored by the healthcare team for possible deteriorations?

Did the patient understand which symptoms required medical assistance?

These are just a few of the types of questions that should be answered to help determine all the Causal Factors. There could be multiple things that went wrong. TapRooT® doesn’t stop at Causal Factors. Each Causal Factor is taken through the TapRooT® Root Cause Tree to find the Root Causes. Just like there may be (and probably is) more than one Causal Factor, there is probably more than one Root Cause that needs to be fixed to prevent this from happening again.

Mark Paradies recently posted an article that may be helpful in a situation like this, “Root Cause Analysis for the FDA.”

It takes some deep diving to understand all of the lessons learned here. Learn more about how to prevent unnecessary deaths like this in one of our upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Trainings:

October 2: Knoxville, Tennessee

October 16: Orlando, Florida

October 23: Bogota, Colombia (Spanish)

October 30: Reykjavik, Iceland

November 13: Brisbane, Australia

November 13: New Orleans

November 27: Johannesburg, South Africa

November 27: Monterrey, Mexico

November 27: Perth, Australia

Building a Safety Culture

May 26th, 2017 by

A Safety Culture can be defined as “the sum of what an organization is and does in the pursuit of safety”. Managing company culture is a task of the corner office; top management needs to embrace the safety mindset -that every employee and customer is free from harm.

In the health care field The Joint Commission (an accreditation organization for hospitals) takes patient safety very seriously. Their document, “11 Tenets of a Safety Culture” (https://www.jointcommission.org/assets/1/6/SEA_57_infographic_11_tenets_safety_culture.pdf) contains a lot of wisdom that can be applied in continuous safety improvement everywhere:

  1. Apply a transparent, nonpunitive approach to reporting and learning from adverse events, close calls and unsafe conditions.
  2. Use clear, just, and transparent risk-based processes for recognizing and distinguishing human errors and system errors from unsafe, blameworthy actions.
  3. CEOs and all leaders adopt and model appropriate behaviors and champion efforts to eradicate intimidating behaviors.
  4. Policies support safety culture and the reporting of adverse events, close calls and unsafe conditions. These policies are enforced and communicated to all team members.
  5. Recognize care team members who report adverse events and close calls, who identify unsafe conditions, or who have good suggestions for safety improvements. Share these “free lessons” with all team members (i.e., feedback loop).
  6. Determine an organizational baseline measure on safety culture performance using a validated tool.
  7. Analyze safety culture survey results from across the organization to find opportunities for quality and safety improvement.
  8. Use information from safety assessments and/or surveys to develop and implement unit-based quality and safety improvement initiatives designed to improve the culture of safety.
  9. Embed safety culture team training into quality improvement projects and organizational processes to strengthen safety systems.
  10. Proactively assess system strengths and vulnerabilities, and prioritize them for enhancement or improvement.
  11. Repeat organizational assessment of safety culture every 18 to 24 months to review progress and sustain improvement.

A formal safety culture statement like this is a good start. To avoid it becoming a “flavor of the day” initiative, it is important to put in place a robust root cause analysis method like TapRooT®. This lends immediate support to Tenets 1. and 2. above.  It is also important to empower employees at every level to stop risky behavior.

Every organization benefits from an objective and impersonal way of investigating or auditing safety incidents, that gets to the root causes. Instead of blaming, re-training or firing individuals more effective corrective actions can be implemented, and safety issues dealt with once and for all.

#TapRooT_RCA

Healthcare Professionals! Please come visit the TapRooT® Booth at the NPSF Conference

May 10th, 2017 by

If you are coming to the conference (May 17 – 19), please stop by and see us at Booth 300; Per Ohstrom and I will both be there.

Of course TapRooT® can help you with patient safety and reducing Sentinal Events. But there are many more ways to use TapRoot® in your hospital:

Improve Employee Safety and reduce injuries

Improve Quality, reduce human error, and make your processes more efficient

We hope to see you there. We have a free gift for the first 500 people, so don’t miss out!

What’s Wrong with this Data?

March 20th, 2017 by

Below are sentinel event types from 2014 – 2016 as reported to the Joint Commission (taken from the 1/13/2017 report at https://www.jointcommission.org/assets/1/18/Summary_4Q_2016.pdf):

Summary Event Data

Reviewing this data, one might ask …

What can we learn?

I’m not trying to be critical of the Joint Commissions efforts to collect and report sentinel event data. In fact, it is refreshing to see that some hospitals are willing to admit that there is room for improvement. Plus, the Joint Commission is pushing for greater reporting and improved root cause analysis. But, here are some questions to consider…

  • Does a tic up or down in a particular category mean something?
  • Why are suicides so high and infections so low?
  • Why is there no category for misdiagnosis while being treated?

Perhaps the biggest question one might ask is why are there only 824 sentinel events in the database when estimates put the number of sentinel events in the USA at over 100,000 per year.

Of course, not all hospitals are part of the Joint Commission review process but a large fraction are.

If we are conservative and estimate that there should be 50,000 sentinel events reported to the Joint Commission each year, we can conclude that only 1.6% of the sentinel events are being reported.

That makes me ask some serious questions.

1. Are the other events being hidden? Ignored? Or investigated and not reported?

Perhaps one of the reasons that the healthcare industry is not improving performance at a faster rate is that they are only learning from a tiny fraction of their operating experience. After all, if you only learned from 1.6% of your experience, how long would it take to improve your performance?

2. If a category like “Unitended Retention of a Foreign Body” stays at over 100 incidents per year, why aren’t we learning to prevent these events? Are the root cause analyses inadequate? Are the corrective actions inadequate or not being implemented? Or is there a failure to share best practices to prevent these incidents across the healthcare industry (each facility must learn by one or more of their own errors). If we don’t have 98% of the data, how can we measure if we are getting better or worse? Since our 50,000 number is a gross approximation, is it possible to learn anything at all from this data?

To me, it seems like the FIRST challenge when improving performance is to develop a good measurement system. Each hospital should have HUNDREDS or at least DOZENS of sentinel events to learn from each year. Thus, the Joint Commission should have TENS or HUNDREDS of THOUSANDS of sentinel events in their database.

If the investigation, root cause analysis, and corrective actions were effective and being shared, there should be great progress in eliminating whole classes of sentinel events and this should be apparent in the Joint Commission data.

This improved performance would be extremely important to the patients that avoided harm and we should see an overall decrease in the cost of medical care as mistakes are reduced.

This isn’t happening.

What can you do to get things started?

1. Push for full reporting of sentinel events AND near-misses at your hospital.

2. Implement advanced root cause analysis to find the real root causes of sentinel events and to develop effective fixes that STOP repeat incidents.

3. Share what your hospital learns about preventing sentinel events across the industry so that others will have the opportunity to improve.

That’s a start. After twelve years of reporting, shouldn’t every hospital get started?

If you are at a healthcare facility that is

  • reporting ALL sentinel events,
  • investigating most of your near-misses,
  • doing good root cause analysis,
  • implementing effective corrective actions that
  • stop repeat sentinel events,

I’d like to hear from you. We are holding a Summit in 2018 and I would like to document your success story.

If you would like to be at a hospital with a success story, but you need to improve your reporting, root cause analysis and corrective actions, contact us for assistance. We would be glad to help.

The Joint Commission Issues Sentinel Event Alert #57

March 6th, 2017 by

Here’s a link to the announcement:

https://www.jointcommission.org/sea_issue_57/

Here are the 11 tenants they suggest:

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To broaden their thoughts, perhaps they should read about Admiral Rickover’s ideas about his nuclear safety culture. Start at this link:

http://www.taproot.com/archives/54027

And then healthcare executives could also insist on advanced root cause analysis.

The Blame Culture Hurts Hospital Root Cause Analysis

November 22nd, 2016 by

If you don’t understand what happened, you will never understand why it happened.

You would think this is just common sense. But if it is, why would an industry allow a culture to exist that promotes blame and makes finding and fixing the root causes of accidents/incidents almost impossible?

I see the blame culture in many industries around the world. Here is an example from a hospital in the UK. This is an extreme example but I’ve seen the blame culture make root cause analysis difficult in many hospitals in many countries.

Dr. David Sellu (let’s just call him Dr. Death as they did in the UK tabloids), was prosecuted for errors and delays that killed a patient. He ended up serving 16 months in high security prisons because the prosecution alleged that his “laid back attitude” had caused delays in treatment that led to the patient’s death. However, the hospital had done a “secret” root cause analysis that showed that systemic problems (not the doctor) had led to the delays. A press investigation by the Daily Mail eventually unearthed the report that had been kept hidden. This press reports eventually led to the doctor’s release but not until he had served prison time and had his reputation completely trashed.

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If you were a doctor or a nurse in England, would you freely cooperate with an investigation of a patient death? When you know that any perceived mistake might lead to jail? When problems that are identified with the system might be hidden (to avoid blame to the institution)? When your whole life and career is in jeopardy? When your freedom is on the line because you may be under criminal investigation?

This is an extreme example. But there are other examples of nurses, doctors, and pharmacists being prosecuted for simple errors that were caused by systemic problems that were beyond their control and were not thoroughly investigated. I know of some in the USA.

The blame culture causes performance improvement to grind to a halt when people don’t fully cooperate with initiatives to learn from mistakes.

TapRooT® Root Cause Analysis can help investigations move beyond blame by clearly showing the systemic problems that can be fixed and prevent (or at least greatly reduce) future repeat accidents.Attend a TapRooT® Root Cause Analysis Course and find out how you can use TapRooT® to help you change a blame culture into a culture of performance improvement.

Foe course information and course dates, see:

http://www.taproot.com/courses

Infection Control: Corrective Actions Much More Expensive then Proactive Improvement

October 3rd, 2016 by

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Here’s a story about a healthcare facility who has agreed to hire an infectious control consultant as part of an agreement to fix problems found by regulators.

What I found interesting is that the original inspection found “11 years of misconduct that led to the contamination of surgical instruments, among other issues.” What this really tells me is that no one was looking at normal day-to-day practices at the center. If there had been a robust audit and observation program, they probably would have been able to do their own internal improvements at much lower cost and without the attendant loss of confidence in their facility.

Learn about using TapRooT® proactively in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

Monday Accident & Lessons Learned: Baby Dies After Oxygen Mix-Up at Hospital in Australia

September 12th, 2016 by

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Here’s a link to the story: http://www.abc.net.au/news/2016-07-25/baby-dies-at-bankstown-lidcombe-hospital-after-oxygen-mix-up/7659552

An Oxygen line had been improperly installed in 2015. It fed nitrous oxide to a neonatal resuscitation unit rather than oxygen.

The Ministry of Health representative said that all lines in all hospitals in New South Wales installed since the Liberal government took over in 2011 will be checked for correct function. 

What can you learn from this?

Think about your installation and testing of new systems. How many Safeguards are in place to protect the targets?

Blame Culture: Doctors Can’t Discuss Errors

August 31st, 2016 by

Perhaps they should be learning how TapRooT® stops blame and finds real root causes that can be corrected.

Medical Errors: Are You Preventing Pressure Ulcers?

August 26th, 2016 by

Medical Error Prevention

My wife was in a cast a few years ago. After about a day, she noticed it was itchy on the bottom of her foot, near her big toe. We didn’t think anything of it (never in a cast before). When we went in for a checkup after a few days, she told the doctor. They pulled off the cast and found a blistery area on the bottom of her foot. It was caused by a slight pressure from a bump in the cast, which cut off blood flow to that small area on the ball of her foot. It ended up being pretty minor (big blister the size of a half dollar), and it healed up just fine.

I was amazed to find out that this can be fairly common after only a few hours in a stationary position, for example, during surgery. They can turn out to be very painful and potentially disfiguring. DO NOT, under any circumstances, Google for pictures of pressure ulcers!

Here is a guide on how the medical community can help prevent pressure ulcers. It is meant to be a proactive means of looking for opportunities to prevent or detect the circumstances and risk factors associated with perioperative pressure injuries.

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Stopping Future Accidents by Correcting Problems That Did Not Cause The Accidents Being Investigated Submitted by: James Watson, Regional Specialist, System Safety Branch FAA, Alaska Challenge TapRooT® investigation often identify actions and conditions that didn’t cause the actual accident being evaluated but that could be significant and, if not corrected, could combine with other factors …

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