Category: Medical/Healthcare

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.

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

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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

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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

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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
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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

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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

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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

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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.

The Power of Positive Rewards (and It’s Not What you Think!)

April 1st, 2016 by

In our classes we talk about enforcement, changing behavior, and creating the workplace we all envision we should have. Through all these discussions around behavior we talk about moving from Infrequent, Uncertain Negatives, to the use of Soon Certain Negatives to quickly change behavior. Producing a culture of “Reluctant Compliance” because no one is happy with this negative change but are forced to comply to avoid negative reinforcement. This “Reluctant Compliance” over time will turn into the norm, the reality of working in a strictly run workplace. Once the compliance is the norm and deviation is the oddity we can then transition to the next critical step… moving on to the use of Soon Certain Positives to create a long-term positive environment.

Within this Soon Certain Positive phase there is the discussion of using rewards in place of discipline to enforce the correct behaviors. So what is a reward? According to Merriam-Webster online dictionary, a reward is the following:

“to give money or another kind of payment to (someone or something) for
something good that has been done”

So by that definition we can look at the following rewards:

  • Money or financial incentive
    1. Cash, donation
  • Some kind of gift or recognition
    1. Coffee mug, plaque, pizza for lunch

When I look at the list above and I think of even simpler rewards that can be provided in the workplace. On that brings my mind back to a simpler time in life… kindergarten. Thinking back, how were we rewarded then? With one simple phrase,”Great Job!”

Being told that you are performing well along with a pat on the back or pat on the head meant the world. If we translate that into adulthood, that same phrase (although it can be used in the same way) is usually translated into a much more infrequently used comment, ”Thank you!” Truly the simplest form of recognition is to be told, “Great job, and thank you.”

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Recognition, if used genuinely, can be one of the greatest forms of behavioral modification.


This kind of recognition if used genuinely can be one of the greatest forms of behavioral modification. Both for the thank-er and for the thank-ee. Both benefit from the recognition of a job well done and the simple note that someone truly has seen and recognizes that, and even more importantly appreciates it.

If you would like to read a great article on the use of this simple form of behavior modification and humanity, read the following article:

http://www.beckershospitalreview.com/hospital-management-administration/the-two-words-you-need-to-use-more-in-your-hospital.html

The article talks about the Healthcare environment but can translate into any workplace in the world. The simplest of things can have the greatest of impacts.

If you enjoy articles like these, please sign up for our weekly Friends & Experts eNewsletter, delivered to your inbox every Tuesday morning.  Email Barb at editor@taproot.com to subscribe today!

 

Protection Through Prevention – A Study in Root Cause Analysis of Patient Safety Events

March 24th, 2016 by

As we on focus patient safety during this week, I thought it prudent to examine one of the more important aspects of providing a safe environment of care for our patients, the use of Root Cause Analysis (RCA) to prevent future events.  If we perform very thorough objective analysis, we can build corrective and preventative measures that will improve our systems and reduce or remove the chances for future similar events.

In the case study below, we’ll examine a medication error that affected one patient, could have affected two patients (due to swapped medications) but did not due to the quick response by the treatment team.  Learn to better analyze and create a safer environment for our patients, staff, and community.

DOWNLOAD this white paper.

 

The Use of the Safeguard Hierarchy in Healthcare

March 17th, 2016 by

I often wonder about the thought process that goes into corrective and preventative measures. My gut feeling is that many times we go straight to the same old ideas because they are comfortable, we have knowledge of them due to past use, or simply because they are easy. Whatever the reason, I think we need to remember as TapRooT® users we have many tools at our disposal (SMARTER, Corrective Action Helper®, and Safeguards) to aid us in building better fixes.

A friend told me a story about the death of a relative due to a Unintended Retained Foreign Object (URFO). Due to the object, he ultimately succumbed to an infection and died. So I did some digging and found an article (http://www.beckershospitalreview.com/quality/4-strategies-to-prevent-unintended-retention-of-foreign-object.html) that talked about four strategies from TJC to help reduce URFO’s and started thinking about our Safeguard Hierarchy. When evaluating corrective actions we need to think in terms of protection, protecting the Target from the Hazard.  In this case the Target is the Patient and the Hazard is the URFO.

So in line with this, let’s examine our hierarchy of Safeguards and see how it compares to our strategies:

All Safeguards Are Not Created Equal
Examining this list, I would suggest that the first 2 on the list, Remove the Hazard and Remove the Target are out at this point. You will always have a Target (patient) and with technology as it is today we cannot remove the need for tools/instruments/sponges et cetera. So we are truly working in the lower four items on the list.

With that in mind let’s look at the 4 strategies proposed by TJC:

Count process: Standardize policies for all procedures, not just those involving an open chest or abdomen. It should be the entire team’s responsibility to reconcile the count. If one member wants the count repeated, the team should comply.

Team communication in the OR: Call out when and instrument is placed in the body cavity and not promptly removed. When a policy deviation occurs, all staff should be capable and comfortable with speaking out and driving issues up the chain of command.

Tools: Items like white boards, sponge trees, radio-frequency identification technology and others should be available whenever invasive procedures are performed. Staff should be held accountable in regards to consistently utilizing these tools.

Standardize the layout: The physical space of a procedural areas should be as close to replicable as possible. While locations may vary, the equipment available should be consistent. Also, cap the number of people allowed in the procedure room. An excess of individuals in the procedural space can increase noise levels, alter visibility and ultimately distract staff.

With a simple analysis we can squarely see that these all fall within the scope of items 4-6 on the Safeguard list above with two of the recommendations falling within the scope of #4 (Standardize the layout) which deals with workspace design. The other two deal with standards and policies for both communication and the process for counting. Even one of the items (Tools) is a crossover action between standards and policies and holding folks accountable. So truly we are 1.5 actions dealing with the workspace, and 2.5 dealing with policies and procedures.

One thing that is a common thread amongst all these items is that they all depend on Human Performance to be truly effective. And although we do not want to see it or believe it, this is the weakest of all safeguards, the reliance on people. But, the fact is, our caregivers are ultimately responsible. Is it any wonder that we see the following comments regarding URFO’s?

While the frequency of URFOs dipped in 2013 after holding the No. 1 position of most frequently reported sentinel event in 2011 and 2012, the numbers trended upward in 2014 and in 2015 they emerged again as the most frequently reported sentinel event.

When we implement safeguards near the bottom of the safeguard hierarchy they will quickly raise the awareness on the issue, thus the dip in URFO’s, but over time they will not be effective (alone or in part) in truly changing the behaviors that cause these issues. We need to shift our focus to the top of the hierarchy if at all possible to truly impact performance.

If topics like this interest you, I’m leading a medical track at the 2016 Global TapRooT® Summit.  Breakout sessions include:

  • 7 Deadly Sins of Human Performance
  • TapRooT® Changes for the Medical Community
  • Human Error Causes of Quality Problems
  • Writing TapRooT® Driven Preventative & Corrective Actions Workshop
  • Anatomy of a Medical Investigation & more!

GO HERE to view or download a .pdf brochure.

Is 17% Compliance Good Enough in Healthcare?

March 11th, 2016 by
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Why do we have such low compliance?

Read a recent study that stated only 17.4% of ambulatory care nurses (surveyed) comply with all 9 precautions for infection control. Now first, for those who didn’t click above to see how the data was collected, I will let you know that this is SELF-REPORTED data (glean what you will from that tidbit of information). I would bet that compliance is actually much lower causing even greater concern.

To be fair, we are evaluating 9 different precautions. I will say that any statement that includes “wash hands” has low compliance … just walk into any men’s restroom to see that. But what would drives this? Let’s examine the items because it must be impossible to complete all of these, right? Here is the list:

  1. Provide care considering all patients as potentially contagious
  2. Wash hands after removing gloves
  3. Avoid placing foreign objects on my hands
  4. Wear gloves when exposure of my hands to bodily fluids is anticipated
  5. Avoid needle recapping
  6. Avoid disassembling a used needle from a syringe
  7. Use a face mask when anticipating exposure to air-transmitted pathogens
  8. Wash hands after providing care
  9. Discard used sharp materials into sharp containers

As a non-healthcare professional I don’t see a whole lot I disagree with. I mean, you are working with sick people, washing hands, wearing gloves, watch out for bodily fluids… can’t argue with that. So why do we have such low compliance? And remember this is “infection control,” so keeping healthcare professionals and other patients and staff safe.

Well, on our Root Cause Tree® we have a root cause under Management System->SPAC Not Used named, “No way to implement.” I bring this up simply to examine what we request in this list versus the very very dynamic environment in the hospital.

Can it be reasonable (except for the human self-preservation gene) to expect all of these to happen when working to save a coding patient? Or in a situation when an ER has very high census with multiple traumas (a situation I witnessed myself yesterday)?

I guess the answer truly is no. We are providing a SPAC that as written is reasonable, but can be difficult to implement during certain times. Thus, the very honest self-reported numbers.

Interestingly enough, I know the TapRooT®ers out there are all saying, “Hey dude, this is more of an Enforcement NI thing,” (you know you just did that, don’t act like you didn’t), but is it really Enforcement NI? I don’t believe in any way shape or form that you could enact an enforcement mechanism for all nine of these things, all at the same time, and give healthcare professionals the ability to perform timely patient care. The process would be so burdensome that it would crumble under the weight of its own scrutiny and patient care would suffer.

So is 17.4% compliance enough? Probably not, but let’s also remember what we are asking for people to do for that compliance. The number may not be acceptable, or palatable, but is what we can expect based on what is asked of these courageous folks working in this very difficult environment.

What do you think? Leave your comments below.

If this topic interests you, check out our medical track at the 2016 Global TapRooT® Summit.  Breakout sessions include:

  • 7 Deadly Sins of Human Performance
  • TapRooT® Changes for the Medical Community
  • Human Error Causes of Quality Problems
  • Writing TapRooT® Driven Preventative & Corrective Actions Workshop
  • Anatomy of a Medical Investigation & more!

GO HERE to download a .pdf brochure!

Does A Good Quality Management System equate to Compliance?

March 8th, 2016 by

book_graphic_1511

If it is written down, it must be followed. This means it must be correct… right?

Lack of compliance discussion triggers that I see often are:

  • Defective products or services
  • Audit findings
  • Rework and scrap

So the next questions that I often ask when compliance is “apparent” are:

  • Do these defects happen when standard, policies and administrative controls are in place and followed?
  • What were the root causes for the audit findings?
  • What were the root causes for the rework and scrap?

In a purely compliance driven company, I often here these answers:

  • It was a complacency issue
  • The employees were transferred…. Sometimes right out the door
  • Employee was retrained and the other employees were reminded on why it is important to do the job as required.

So is compliance in itself a bad thing? No, but compliance to poor processes just means poor output always.

Should employees be able to question current standards, policies and administrative controls? Yes, at the proper time and in the right manner. Please note that in cases of emergencies and process work stop requests, that the time is mostly likely now.

What are some options to removing the blinders of pure compliance?

GOAL (Go Out And Look)

  • Evaluate your training and make sure it matches the workers’ and the task’s needs at hand. Many compliance issues start with forcing policies downward with out GOAL from the bottom up.
  • Don’t just check off the audit checklist fro compliance’s sake, GOAL
  • Immerse yourself with people that share your belief to Do the Right thing, not just the written thing.
  • Learn how to evaluate your own process without the pure Compliance Glasses on.

If you see yourself acting on the suggestions above, this would be a perfect Compliance Awareness Trigger to join us out our 2016 TapRooT® Summit week August 1-5 in San Antonio, Texas.

Go here to see the tracks and pre-summit sessions that combat the Compliance Barriers.

Interesting Opinion Article About Hospital Ratings

March 2nd, 2016 by

NewImage

Gary Passama, CEO of Northbay Healthcare, wrote an interesting article titled:

Beware of Ratings

 Click on the link above and see what you think. 

It certainly would be nice to have accurate ratings so that patients could choose the best providers. What would it take to make it happen?

Communication’s Role in Healthcare Events

March 2nd, 2016 by
crutches-538883_1280

Ensure messages sent match messages heard.

Communication has always been an issue within healthcare. From the earliest days of TJC alerts and the Event RCA guidance, communication has been a focus. There are multiple communication threads between practitioners, nurses, patients and family that create many avenues for possible problems.

As an example, I will use a story told to me by a friend regarding a recent surgical procedure. I will not try to recount the actual surgery as it is not truly relevant to this discussion. I will, however,  start this story in Recovery after the person underwent surgery with no complications. During post-surgery recovery, they were provided with their formal discharge instructions from the nurse which included the following:

1) No lifting over 25 lbs for 1 week.
2) May return to work the next day.
3) Other medicine related and wound care information included.

After getting these instructions but before being discharged the surgeon came by to check on the patient and briefly discuss the procedure. During the discussion the following exchange occurred:

Patient asked the surgeon “Can I go back to work Monday?”

Surgeon asked, “What do you do?”

Patient answered, “Course setup and planning.”

Surgeon answered without hesitation, “You should be able to go back to work and perform that job without an issue”.

End of discussion.

See any potential problems with this communication? Any conflicting information? Very interesting isn’t it? Now, if we examine the duties within “Course setup and planning”:

1) Packing boxes
2) Shipping boxes
3) Lifting boxes
4) Computer work
5) Course Documentation

We can immediately determine that this job should be restricted based on the original instructions provided by the RN in the formal discharge instructions. But as with most people the words and advice from the surgeon were the ones that were heeded. My friend went to work on the next work day and continued to lift boxes that were in fact greater in weight than what was allowed. Now, in this case there was no additional injury, there were no complications, but this showed me in a glaring way how communications could cause a problem.

Now, had my friend had a complication and was forced to go back and receive an additional surgery, would this issue have been found as part of the RCA (if one were performed)? Did the communication have a role in the event? Here is a possible causal factor:

BoxLift
Examining this causal factor, it is easy to see that the communication would play a role in this issue. When taking this through the Root Cause Tree® we would likely answer yes to the question “Did verbal communication or shift change play a role in this problem?”. This would lead us to the Communication Basic Cause Category on the back of the Root Cause Tree® where we would examine those possible Communication related causes.

So during the examination of any event whether high or low risk, it is important to consider the impact of the spoken word. Looking into all communications that are involved to ensure that the messages sent match the messages heard. And that there are no conflicting communications that can cause confusion or set the patient or family up for failure. If you would like more information on how to consistently analyze healthcare related events using TapRooT® please feel free to contact me at: skompski@taproot.com.

Learn more about Healthcare RCA at the 2016 Global TapRooT® Summit.

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