Category: Medical/Healthcare

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 their 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:

NewImage

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.

Screen Shot 2016 11 22 at 11 09 45 AM

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

Infection 2

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

Image008

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.

Hand Hygiene: Patient Safety Through Infection Control

August 24th, 2016 by

Hand Hygiene_Patient Safety Through Infection Control

I remember my mom telling me to “wash my hands before supper”. Something that we all should know how to do, yet vitally important in the medical community.

How hard can it be to wash your hands? If I told you to “Wash your hands before changing that bandage,” how would you do it? What soap would you use? How do you dry your hands afterwards? At what point in the procedure do I actually have to wash your hands? As you can see, there are lots of opportunity to make a mistake and cause a problem, unless you have the answers to these questions.

Hand Hygiene: A Handbook for Medical Professionals is an about-to-be-released book on how to properly hand infection control in a variety of circumstances.  It puts all of these lessons learned into a single reference for a professional to figure out the right way (and the wrong way) to prevent the spread of infections between patients.

The Joint Commission Summary of Sentinel Events – 2Q 2016

August 22nd, 2016 by

Clamp

 

Here’s a summary for reported sentinel events for the 2nd quarter of this year, compiled by The Joint Commission. It also compares some of the data against previous years.
It is almost impossible to make accurate comparisons on this data, since all reports are voluntary and, as stated in the report:

Data Limitations: The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

Without knowing who is reporting, who is not reporting, how these numbers are compiled or arrived at, how the problem types are assigned, etc., I’m having a tough time viewing the data in an objective light.

While the data is interesting, I’m not sure how this data is used.  Can anyone give me an example of how the data in this summary might be used?

Ed Skompski invites you to the Medical Track at the 2016 Global TapRooT® Summit

July 11th, 2016 by

The Global TapRooT® Summit offers multiple focused learning tracks. This video introduces the Medical track for healthcare professionals. Come to the Summit and maximize improvement at your company!

REGISTER for the 2016 Global TapRooT® Summit.

Interested in the Investigation Track? Learn about it here!

Interested in the Asset Optimization Track? Learn about it here!

Interested in the Safety Track? Learn about it here!

Interested in the Quality Track?  Learn about it here!

Healthcare: Can’t See the Forest for the Trees

July 5th, 2016 by

black-forest-1476021_1920

My grandmother (with whom I spent many of my childhood weekends) would say to us grandkids, “You can’t see the forest for the trees!” That usually came right after something bad happened or we did something that was not considered “right” by the adults. I always wondered what that meant, I have thought about it for years and I believe from an adult perspective I finally get it… Granny Lillie, if you can hear this, “I FINALLY GET IT!” (I hear her saying, “It is about time……sheesh.”)

As I have worked with healthcare organizations over the past 20 years working to improve performance and improve their systems we always talked about examining failures and finding the causes. Finding the “Whys” is the step necessary for you to fix issues that existed. Those issues that underlie our systems and turn into incidents, accidents and breed adverse behaviors have to be removed following a problem so that we can prevent reoccurrence. This is preached, taught, and required by all organizations in today’s business world. But why do we wait, why do we have to fail to learn? That question has always concerned me. This is where my grandmother fits in…

When as kids we would go out, make decisions to do things that had adverse outcomes, she would always say to us “you can’t see the forest for the trees” and we would just nod our heads and say “ok” then continue on our merry way. Not only would we not learn from our mistakes but we could not see the mistakes and incidents they happened. The correlation in today’s adult world from an organizational perspective relates to making decisions without considering the consequences. The “Trees” from the statement above is the change you are going to make. If you focus on the “Trees” in front of you and do not consider the future beyond that “the Forest” you are taking unnecessary risk and possibly creating problems. Do you “get it”?

What got me thinking about this today came from an article  I read which dealt with an investigation by the State’s Office of Inspector General at a Louisville, KY hospital. This along with the TJC visit which found many problems at the facility prompted concerns. The investigation was prompted by complaints by staff (that survived the downsizing) regarding health and safety issues due to the decreased staffing. After reading the article I immediately began thinking about our Proactive Flow within the TapRooT® process.

Proactive Flow
We talk about being Proactive in place of reactive and one thing I always mention in my classes is using the TapRooT® process to look at the process before a change or implementation and after that implementation to see where there may be gaps or issues that are identified. This proactive approach may raise questions before you commit to change.

Notice that when we get to step 3 in the Proactive flow we take the observed issues or problems and ask the simple question, “What could result from this?” We would pose this question against our view of the future system. Let’s suppose that they had recognized these future conditions:

  1. A reduction in staffing would create a significantly higher workload for existing staff
  2. Hospital maintained customer/patient throughput with reduced staffing
  3. Using traveling nurses with little or no facility or system related training to supplement staffing levels
  4. Reduced staffing could cause difficulty in maintaining the Quality Control standards due to pressure based on census

We can now take this information and use that “What could result from this?” and we could have had this conclusion:

PSafetySnapCharT-ProActive
Now notice that the Significant Issue identified has a dotted line around it meaning it is an assumption, but the possible outcome that could have been recognized (which later became a reality) could have been taken through the Root Cause Tree® and analyzed before it became a reality. And you would have likely come to several areas on the back of the Root Cause Tree®:

a) Training – No Training – Decided not to Train
b) Management System – Standards, Policies and Administrative Controls NI – Not Strict Enough
c) Work Direction – Preparation – Scheduling NI
d) Work Direction – Selection of Worker – Not Qualified

And there certainly could have been others. At this point you have the ability to re-evaluate the changes you are about to make and ensure that the programs put in place following this down-sizing remove these potential problems. This allows you to evaluate the “Forest” behind those “Trees” and ensure the safety of your future patients and staff while working through the “Forest.” If this one hospital had performed this analysis the outcome and where they are today could have been significantly different.

By using this thought process and by being Proactive we can all create safer systems, create a more effective and acceptable working environment, and protect those around us that depend on us… just as Granny Lillie tried to do for us kids so many years ago. Sometimes the simplest, most practical viewpoint is the best. If you have any questions about the TapRooT® process for Proactive assessments please contact me directly at skompski@taproot.com.

Can Healthcare Benefit from Procedure Usage?

June 27th, 2016 by

chemotherapy-448578_1280

Don’t think checklists are useful in healthcare? Read on!

I was teaching a class (not in the healthcare arena) and had some interesting discussions around the use of procedures during work. First let’s recap the TapRooT® Definition of a procedure:

A procedure is a written step-by-step description of how a particular task is to be performed that is read and followed during performance of the work by the person performing the work.

A checklist is considered a procedure in our system. For this company there were two perceptions regarding procedures and their uses:

  1. Those are only necessary if there are people who are not knowledgable on the task.
  2. Those procedures always make work more difficult.

Now, I have heard these comments before from folks in the healthcare field when the work procedure is used not for a medical “procedure” but when it is used as a checklist. Many doctors and nurses don’t like having to follow a specific path towards medical treatment. And I agree because each human is different, each course of treatment is different, and every scenario is different that it is more difficult to set procedures for every medical treatment. But can tasks and scenarios benefit from the use of checklists within healthcare?

The following article talks about the use of checklists and examined 10,700 surgical procedures. The results although only showing small decreases did show that the implementation of quality checklists dealing with Surgical Safety reduced the following:

Length of Stay from 10.4 to 9.6 days
30-day Readmission Rates from 14.6 to 14.5%
90-day Death Rates from 2.4 to 2.2%

Small numerical changes equate to large numbers in the overall scheme of healthcare. From a 2010 National Hospital Discharge Survey and the National Center for Health Statistics showing some 51.4 million inpatient surgeries performed, that means that we can reduce the number of readmissions by 51,400 patients, and the 90-day death rate means we lower the number of deaths by 102,800 patients. Now I am not sure if you agree but that is a SIGNIFICANT impact on patient care. Those are numbers that could provide pause for those who don’t think checklists can be used in healthcare!

Now going back to our two objections above, let’s now think about why procedures, when implemented and designed properly, can improve performance.

Those are only necessary if there are people who are not knowledgeable on the task.

Procedures can be built to contain a level of information that can be helpful to both experienced and non-experienced practitioners. The idea that just because you have a lot of experience that you cannot make a mistake is unacceptable today. We are fallible, we are human, so why can’t we accept help? I believe it is perception, see comment 2 above:

Those procedures always make work more difficult.

Perception is reality and if people don’t believe or understand why you implement these checklists and don’t implement them effectively then this is understandable.
Here is what checklists help you do:

  1. Not rely on short-term memory
  2. Become more consistent in an approach to a job
  3. Remind and caution against unsafe behaviors
  4. Document the way work is “expected” to be performed

These four items alone are work an additional 2-3 minutes of time it takes to address and use the checklist, don’t you think?

From the numbers above, and the possible impact on patient care the use of checklists where reasonable is a very simply and effective way to raise the level of performance of your staff and have a very positive impact on patient care. If you would like more information on this or other topics around the TapRooT® system and how it impacts human and equipment performance please feel free to contact me at skompski@taproot.com.

Handwriting and RCA

June 20th, 2016 by

Today’s article is meant to create a discussion. We all know that Electronic Medical Records (EMR) are taking the place of written orders in healthcare (providing their own set of issues), so where does the written word fall on the Root Cause Tree®?

The cartoon below illustrates the issue we are discussing:

Handwriting
Back in the day doctors and nurses always used written records, or prescriptions. Today the reliance on this form of communication is less than in the past but can still cause issues. One question to ask yourself is, “Is the burden of understanding written communication on the writer or the reader?”  What is your opinion on this? Mine is that it is most certainly on the writer. We should not provide communications of any kind that have to be interpreted to be understood. Going back that is why many acronyms have been removed from healthcare…they simply created confusion.

So thinking about written communication, if we have a Causal Factor dealing with a nurse or physician did something wrong due to a misunderstanding of a written communication…where would we go under the “Human Performance Difficulty” section?

One question that would most likely be a yes is the second question under the Team Performance Section: Did failure to agree about the who/what/when/where of performing the job play a role in this problem?. This leads us to Training, Communications, and Work Direction but does that really match?

For this week please provide your insight into where you believe this issue would fit. Thank you for reading and for providing your insight! I will write about our results in next week’s article! Have a great week……

(P.S. Don’t forget to sign up for my Medical track at the 2016 Global TapRooT® Summit, San Antonio, August 3-5, 2016.)

When is a Root Cause NOT a Root Cause to a Sentinel Event

June 13th, 2016 by

So many times when I review Sentinel Event (SE) analyses for companies, I struggle to find the link between a Root Cause and the data on the SnapCharT®. But at the same time, the Corrective Action provided for that cause makes sense to reduce the likelihood of recurrence. This is perplexing as I did not want to say that the analysis was done poorly or was not correct simply because the outcome would probably be a positive one. Then it hit me, many people when going through the Root Cause Tree® were focusing more on the outcome desired than what the data told them.

Our ultimate goal is to fix a problem, reduce risk, and keep our patients, patients’ families and staff safe. To do so we have to present a very coherent, logical argument back to our administration regarding our analysis and findings. I represent this with the following diagram:

Specific Relationships
There is a “Specific” relationship between an Incident, the related Causal Factors, the Root Causes of those Causal Factors, and the Corrective Actions we recommend. This relationship has to be easily seen by your audience. If there is a break in that connection from the top (Incident) to the bottom (Corrective Actions) there is generally a problem with the analysis.

The issue that prompted this article relates to how people go through the Root Cause Tree®. As the user gets down to the Root Cause level I begin hearing people making declarations, “We could fix this issue by labeling the medication better” and with that statement the team puts a positive checkmark by Labels NI. What is wrong with this statement and action? Nothing upon first glance if it is true that a better label could prevent recurrence.

Digging deeper, these types of thought processes are actually working in reverse of what we teach. We teach to look at the data on the SnapCharT®, read the definitions to determine if the data supports selecting Labels NI. Based on our teachings we should hear statements such as, “Do I have an evidence (on my SnapCharT®) that tells me that the labeling present at the time of the event contributed to this Causal Factor (and thereby to the Incident)?” Notice that one quote is a question and one is a statement and therein lies a key difference. As we work through the analysis we should be questioning our data versus the definitions and items in the Root Cause Tree® not stating how we could fix the issue. Once we have the Root Cause, we can then work on a Corrective Action to fix the Root Cause.

In conclusion if we choose the Corrective Action first followed by a cause that justifies that action, the investigative team has created a break in that “Specific Relationship” from top to bottom. That break is between the Causal Factor/Root Causes and the data collected on our SnapCharT®. Without data on the SnapCharT® to support the Root Causes you present to your management team, you put your analysis in question. Without belief in the analysis management will be less likely to provide you the resources you need to fix issues and improve performance.

If you would like more information on this or any topic relating to the use of TapRooT® in Healthcare feel free to contact me directly at skompski@taproot.com or at (865) 539-2139.

Proactive Improvements in Healthcare

June 9th, 2016 by

We’re so impressed with how a large retail pharmacy approached a problem and their corrective actions not only improved their processes but also earned an impressive award! What can you proactively improve at your facility? How can we help?

If you’d like to learn more about how to be proactive in healthcare, check out our Medical Track at the 2016 Global TapRooT® Summit, August 3-5, San Antonio, Texas.

How Does Senior Leadership Affect RCA in Healthcare?

May 23rd, 2016 by
team-115887_1920

Across industries, senior leadership has some level of impact on every process and system.

I attended the Ohio Association of Healthcare Quality (OAHQ) Conference in Columbus last week and gave a talk on this subject. In any industry there is always some level of impact that senior leadership has on every process and system. From their expectations for the staff through their desire for the organization and business, these expectations become the guidelines within which we work.

When I talk to healthcare professionals I always hear the positive and the negative (usually in reverse order), and it is very rare that anyone is only on one side or the other. There is usually a mix. Some of the things I hear about are as follows:

Negative Impact:

  1. Unreasonable expectations for timelines in determining root causes
  2. Not providing a charter or guideline that provides the responsibilities of the team and communicates the abilities of the team/team leader
  3. Messages communicated from the Administration do not match with the “reality” of our working environment
  4. Corrective Actions that are recommended are not always implemented or followed and are substituted with managements own ideas that are not in alignment with the findings

Positive Impact:

  1. Our team feels like we are provided the necessary support to gather what we need to gather to understand the event
  2. Management supports our efforts to implement corrective and preventative measures following an adverse outcome
  3. The organization is very much a proactive group who truly want and desire to make our systems the best they can be

Now, looking at this list, we truly see how these issues are polar in ways. Different organizations have the opposite opinions from their counterparts. This is to be expected as each organization is different.

Looking at these comments and thinking towards TapRooT® and our Root Cause Tree®/Dictionary, where would these issues (if found to be causal factors) show up in the analysis? Well there is one primary area where I believe these truly match:

Management System – How Policies and the Actions of the Management System Impact the System

Of course this is not the only area that could show up as every investigation is different but these most certainly could have impact. And in addition to that, when investigating events you have to look at the outcomes (not root causes necessarily) from previous similar events. This portion of the analysis will gather data that could lead you to multiple root causes:

Management System->Corrective Actions->Corrective Action NI or Trending NI: If it is found that previous corrective actions were never implemented, or were not as effective as they could be you might be led to and those decisions were directly related to management decisions to change alter or not follow-up to see if the actions worked.

Management System->SPAC Not Used->Enforcement and/or Accountability: When examining events, if it is found that due to a lack of support from senior leadership to uphold investigative charters or uphold the level of responsibility given to the investigative team, then this could most certainly be a Management System issue.

These are just a few examples of how past performance can impact the events you investigate today. My recommendation is to always talk to people in your Management System to understand their expectation and compare that expectation to the actual messages received and heard throughout the organization. Then compare those messages to what happened during the event analysis to assess the actual impact. You might be surprised at what you uncover.

If you would like to know more about the TapRooT® process and our investigative philosophy please contact me directly at skompski@taproot.com or attend one of our training courses held worldwide www.taproot.com/courses and learn how TapRooT can help you improve performance. Thank you for reading!

When the Message does not Communicate the Message in Healthcare

May 16th, 2016 by

This week’s article is not so much based on RCA principles but on the decisions that senior leaders make and the consequences of those actions. I always highlight from an RCA perspective the impact of the messages and communications from senior leadership down through the organization and the possible negative consequences. But this takes the cake… or the donut, if you will.

Saw an article today about the University of North Carolina’s decision to remove the name of their newest (7-month-old) corporate sponsor off of their UNC Children’s Clinic. That corporate sponsor… wait for it…

“Krispy Kreme”

Now, I am surely no marketing genius (my strengths are more in the training and RCA world) but could anyone associated with the organization see past the $$$$ to know that this was not a good idea? In today’s money driven society there are reasons that sponsors are invited, and in most cases these are due to a lack of funding and a desire to continue doing good deeds and good work. But sometimes the word “NO” is very much underutilized.

What message was sent to all those Doctors and Nurses? To all the parents bringing their children for care to the clinic? Is it the health, care and safety of their young loved ones? Or is it something else? I certainly don’t want to be treated for a clogged artery in the “Beef it’s What’s For Dinner Cath lab”, or be treated for a peanut allergy in the “Peanut M & M’s Allergy Center.”

Now if you read the full article the name was tied to a fund-raising race and the Clinic and UNC’s dedication to it. But always remember that what you perceive the message to be may not be what is received. I have worked with investigations where too many times the Administration says one thing and a totally different message is received. From an RCA perspective in the diagram below you will see that the Administration/Management interview circle is dotted… in TapRooT® circles that means an assumption or unknown.  

whotointerview

From a data gathering perspective, this means that I need to compare what Administration/Management believes/says/communicates is what is understood by the masses. To understand if the true message has reached those who need it. And in the case of this article I believe that they totally missed the mark with all the right intentions. Let me know what you believe in the comments below.

If you would like to know more about TapRooT® or if you have any questions you can contact me at skompski@taproot.com or you can find out about our public course offerings at:

www.taproot.com/courses.

 

Hospital Patient Safety – Shouldn’t We Have Made More Progress?

May 10th, 2016 by

This is a TV report from 2007 …

Truthfully, we could make the same video today.

Why haven’t we made more progress to improve patient safety?

Each year we have a Track at the Global TapRooT® Summit about improving patient safety. If the good practices we present each year had been implemented across the country … we would be much better off.

Interested in learning best practices to improve patient safety? Sign up for the 2016 Global TapRooT® Summit in San Antonio, Texas (August 1-5). See the complete schedule by CLICKING HERE. And see the Pre-Summit Courses at this link: http://www.taproot.com/taproot-summit/pre-summit-courses.

Then register for the summit at:

http://www.taproot.com/taproot-summit/register-for-summit

 

 

Can a Difference in Opinions from the Top to the Bottom of a Healthcare Organization Impede Performance?

May 9th, 2016 by

meeting-1219540_1920

Does management have a different perspective on how work is being performed?

I love reading about current events to stimulate the mind and to be in tune with what is happening in the world. Sometimes you simply stumble across an article and it immediately hits home and speaks to you. This article spoke to me and resonated with many questions I am asked during our Root Cause Analysis courses.

When we begin discussing the “Management System” category on our Root Cause Tree®, and get to the “Oversight/Employee Relations” Near Root Cause, I always get a lot of what I will call “Automated” nods. So, I always lead into the discussion talking about how when investigating we need to get a gauge on the messages being sent from the top, and the beliefs at the bottom. In so doing, we end up measuring both sides of a conversation. And many times the messages are the same, with the normal personal spin. But sometimes you come across data that suggests otherwise.

The article discusses the issues with changing EHR systems and impact on care. The discussion has perceptions from different groups within the polling group and there is a startling disjoint from the top down to the organization. See the following two statements:

Nursing staff reported being highly affected by the EHR replacement, but had virtually no say in the replacement decision, according to the survey. While 90 percent of nurses said EHR replacements reduced their ability to effectively provide hands-on care, 96 percent of nurses said they were not included in EHR replacement planning.

vs.

However, just 5 percent of hospital leaders said the EHR replacement process had a negative impact on care, which Mr. Brown said suggests executives are reticent to address the issues. ‘In our experience polling, most executives will not admit they were oversold or that their IT decisions had adverse bearing on patient care,’ Mr. Brown said. ‘On the other hand, workflow changes and productivity issues may have added to the disappointment nurses felt after being left out of replacement EHR product evaluations.’

If I were investigating an incident at one of these hospitals and was interviewing both Administrators and Nurses around a Sentinel Event, this would raise some very large concerns in the organization. Why is there such a large chasm in beliefs here and what kind of impact could this have on performance. In our system this would likely lead us to the Management System->Oversight/Employee Relations->Employee Communications Root Cause. With Management having such a different perspective on how work is being performed, we might answer yes to the following question from our Root Cause Tree® Dictionary:

Did management’s employee communications program fail to communicate management’s concerns for quality workmanship, safety, and the environment?

When a message that is sent from the top of the organization does not support the actual work performance of the organization, employees would certainly believe that the top tier does not show the correct level of commitment to being a high performance organization.

If you would like more information on how TapRooT® can help your hospital or health system become more efficient and provide safer patient care please attend one of our TapRooT® training courses or contact me directly at skompski@taproot.com.

Medical Errors – 3rd Leading Cause of Death in the US

May 4th, 2016 by

Medical Death Chart

Wow. Quite an eye-opening Washington Post article describing a report published in the BMJ. A comprehensive study by researchers at the John Hopkins University have found that medical mistakes are now responsible for more deaths in the US each year than Accidents, Respiratory Disease, and Strokes. They estimate over a quarter million people die each year in the US due to mistakes made during medical procedures. And this does NOT include other sentinel events that do not result in death.  Researchers include in this category “everything from bad doctors to more systemic issues such as communication breakdowns when patients are handed off from one department to another.”  Other tidbits from this study:

  • Over 700 deaths each day are due to medical errors
  • This is nearly 10% of all deaths in the US each year

What’s particularly alarming is that a study conducted in 1999 showed similar results.  That study called medical errors “an epidemic.”  And yet, very little has changed since that report was issued.  While a few categories have gotten better (hospital-acquired infections, for example), there has been almost no change in the overall numbers.

I’m sure there are many “causes” for these issues.  This report focused on the reporting systems in the US (and many other countries) that make it almost impossible to identify medical error cases.  And many other problems are endemic to the entire medical system:

  • Insurance liabilities
  • Inadequate reporting requirements
  • Poor training at many levels
  • Ineffective accountability systems
  • between patient care and running a business

However, individual health care facilities have the most control over their own outcomes.  They truly believe in providing the very best medical care to their patients.  They don’t necessarily need to wait for national regulations to force change.  They often just need a way to recognize the issues, minimize the local blame culture, identify problems, recognize systemic issues at their facilities, and apply effective corrective actions to those issues.

I have found that one of the major hurdles to correcting these issues is a lack of proper sentinel event analysis.  Hospitals are staffed with extremely smart people, but they just don’t have the training or expertise to perform comprehensive root cause analysis and incident investigation.  Many feel that, because they have smart people, they can perform these analyses without further training.  Unfortunately, incident investigation is a skill, just like other skills learned by doctors, nurses, and patient quality staff, and this skill requires specialized training and methodology.  When a facility is presented with this training (yes, I’m talking about TapRooT®!), I’ve found that they embrace the training and perform excellent investigations.  Hospital staff just need this bit of training to move to the next level of finding scientifically-derived root causes and applying effective corrective actions, all without playing the blame game.  It is gratifying to see doctors and nurses working together to correct these issues on their own, without needing some expensive guru to come in and do it for them.

Hospitals have the means to start fixing these issues.  I’m hoping the smart people at these facilities take this to heart and begin putting processes in place to make a positive difference in their patient outcomes.

 

Confidential Medical Records Leak Sinks $4.6 Million Company

April 27th, 2016 by

medical-781422_1280

What are the lessons learned from this incident?

Everything was going great for Michael Daughtery, owner of LabMD, a company that tested blood, urine, and tissue samples for urologists. He was living the dream. That is, until one of his managers who had been using LimeWire file-sharing to download music inadvertently shared patient medical records with it. It was a violation of company policy to have it on her computer.

The story goes from bad to worse. Read “A leak wonded this company. Fighting the Feds finished it off” on Bloomberg.

In one day, your whole life could change.  Wouldn’t it be great if you never got that phone call that disaster has struck your company?

We have several exclusive Pre-Summit Courses coming up in August that can help you keep your company from facing a crisis such as this.  TapRooT® for Audits, Understanding and Stopping Human Error, Risk Assessment & Management and more.

View them here.

We also offer a Medical track immediately following the special 2-day courses at the 3-day Global TapRooT® Summit.  Learn more here.

We hope to meet you in San Antonio, Texas during Global TapRooT® Summit week to help you solve your business-critical issues.

Investigating Healthcare Events: Do We Want to Learn? Are We Committed to Listening?

April 15th, 2016 by

doctor-840127_1920

Research Shows Nurse Staffing Levels Affecting Patient Care.
Is Research Really Necessary to Understand This?

When we investigate events in healthcare, we are looking for the systemic causes of failures, both human performance based and equipment based. When looking at individual events we cannot exclude other related or similar events in our data gathering process as we should be learning from those as well. So if it takes research to see that staffing levels are affecting patient care, then we need to look at our long standing RCA programs and ask are we doing everything we can to understand the bigger picture?

A recent article highlighted this issue with true clarity. The research told us that there is a link between Nurse staffing levels and the quality of care provided. Now, I could go through and show you how TapRooT® helps you find the “Scheduling NI” root cause or the “SPAC NI-> Confusing or Incomplete” root cause and how it fits these types of events. Looking at this I see it in the bigger context of an organization and the bigger picture is understanding and “listening” to the data and what our process is communicating to the organization.

Looking back at the original research and tying things back to RCA it became clear that we have some larger systemic issues that we are not addressing. These may include Trending of RCA data, communication of issue within our hospitals, and data collection during event analyses. Any of these three puzzle pieces could lead us towards the same conclusions found in the above article. So why does it take us so long to see “Generic Issues”? Well here are a couple of my ideas or hunches, if you will, on this issue:

1. Do we truly want to learn or are we satisfying a “requirement”?

Regulation is a necessary evil in our society… many times it seems that doing the “right” things are not as commonplace as it once was. So through regulation we “require” diligence, we require analysis, we legislate what should be done anyway. With this there truly are two trains of thought, compliance mentality and improvement mentality. The compliance mentality is what I highlight here. If we have the compliance mentality we only do because we have to, which usually means meeting the letter of the law and no more. Checking a box does not mean we listen to the data or what our systems are telling us and many times it leads to only the corrective measures we can get away with at a minimum. Is this acceptable when adverse outcomes can cost the lives of the ones we commit to serve, aid and protect?

How do we change this mentality? Understand the value of the use of Root Cause Analysis within the organization and work to make it part of the everyday job of each employee to improve their jobs, their productivity, and empowering them to bring about change in an organization. This means tackling the everyday issues with RCA and not waiting to fulfill a requirement. Expand the scope through empowerment for change.

2. What is our commitment to “listening” versus “hearing”?

Confronted with my own personal family issues around this very issue has brought this to the forefront of my mind. When people are recovering from traumatic injuries and are being helped by others there is a tendency to be overwhelmed by the “claustrophobic” nature of personal care from a loved one. The feeling is that they are complaining at me so much that I am overwhelmed, and am listening but can’t take all this information. When in fact they are “hearing” everything said, but truly are not listening to the messages for various reasons.

This can be like a corporate culture, are they “hearing” or “listening”. There is a huge difference in these two things that many people simply don’t get. Too many times we have people report issues or problems or near-misses because we say “We are Listening to you”, but we truly are only “Hearing you” in the absence of acting on the data. Generic issues (which I have written about before) are something that you have to be willing to “listen” for through your RCA and Report data. Data provided to your organization will tell you a story, it will provide you with indicators or precursors that help you predict the future. Now is it an exact science, no, but it doesn’t have to be if you “listen”. In my opinion too many organizations want to make their employees and clients feel “heard” but are not willing to actually listen and act upon what they are being told.

Changing this behavior is not as simple as it may sound. It is truly a change in the corporate culture of an organization, the “walk the walk” versus “talk the talk” mentality. This can be started simply by the communication from management through to the folks on the front lines of how RCA data and corrective actions are handled. Allowing people to see that they have the ability to enact change. Then making sure that the proper trending and “listening” tools are in place to understand what the reported data is telling you. These two pieces can paint a very cohesive picture of how the organization is performing. Process Behavior Charts, Pareto Charting, and other basic data analysis tools are built into the TapRooT application to aid in doing this.

Within this discussion there are probably many other reasons why we can’t or won’t see the bigger picture and I would love to hear your theories and thoughts on this issue. The two issues I raise above are two good starting points to making your organization more efficient. But improvement opportunities abound throughout your organization, but they can only be found if you are “listening” and heed the messages being sent to you from your employees and from your systems. Don’t wait for research to tell you where your problems are, listen and act upon what you already know and bring your organization ahead of the curve.

If you would like more information about the Trending tools recommended and provided by TapRooT® please feel free to contact me directly at skompski@taproot.com or plan to attend our 2-day Trending Course held before our TapRooT® Summit this August in San Antonio TX.

Connect with Us

Filter News

Search News

Authors

Angie ComerAngie Comer

Software

Barb CarrBarb Carr

Editorial Director

Chris ValleeChris Vallee

Human Factors

Dan VerlindeDan Verlinde

VP, Software

Dave JanneyDave Janney

Safety & Quality

Garrett BoydGarrett Boyd

Technical Support

Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger

Co-Founder

Mark ParadiesMark Paradies

Creator of TapRooT®

Per OhstromPer Ohstrom

VP, Sales

Shaun BakerShaun Baker

Technical Support

Steve RaycraftSteve Raycraft

Technical Support

Wayne BrownWayne Brown

Technical Support

Success Stories

Many of us investigate accidents that the cause seems intuitively obvious: the person involved…

ARCO (now ConocoPhillips)

Reporting of ergonomic illnesses increased by up to 40% in…

Ciba Vision, a Novartis Company
Contact Us