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The latest article comes from the Irish Medical Times. It tells the stories of two deaths from medical errors, the aftermath of litigation, and a failure to learn.

I’ve seen this article dozens of times. It could be written in the US, Canada, the UK, Australia, and many other countries. Which brings me to the question:

Is the Healthcare Industry Ready to Change?

I hope the time has come. Harry Wetz of Integris Health and I have worked hard to develop a useful, diverse, insightful Medical Error Reduction Best Practices Track for the TapRooT® Summit. The knowledge from this track plus the knowledge available about root cause analysis (either in the 2-Day TapRooT® Course or the 2-Day TapRooT®/FMEA Course before the Summit) could help a hospital that is willing to change make major strides to stop medical errors.

What’s in the Medical Error Reduction Best Practices Track? Here’s a list:

• Morbidity & Mortality Reviews (Hot Case Rounds) - Dr. Johnny Griggs, MD, Tommy Garnett & David Davies, PS2C2

• The Human Design Spec: Minimizing Human Error While Working in a 24/7 Medical Environment - Bill Sirois, VP & COO, Circadian Technologies

• MEDCAS - Richard Cook, Anesthesiologist, University of Chicago Medical Center

• Improving Patient Safety & Reducing Risk Go Hand-in-Hand - Leilani Kicklighter, The Kicklighter Group

• Measuring Performance - Dr. Joel Haight, Professor, Penn State

• Process for Running a Healthcare Root Cause Analysis - Tommy Garnett & David Davies, PS2C2

• TapRooT® User Success Stories from Industry & Healthcare - Linda Unger

• “Outside the Box” Creative Solutions - Michele Lindsay, P2, Canada

Also, participants will hear from five very interesting and motivating Keynote Speakers:

• Nikki Stone - Olympic Champion

• Lt. Col. Ralph Hayles - Gulf War I Veteran

• Carolyn Griffiths - Chief Inspector of the UK Rail Accident Investigation Board

• Ed Frederick - Operator during the Accident at Three Mile Island

• Marcia Wieder - America’s Dream Coach

In addition to these great sessions and speakers, there will be outstanding networking and best practice sharing that goes beyond the typical “medical industryt only” sessions. The Summit will have international performance improvement experts from a wide variety of industries who medical industry personnel can share ideas and learn from.

The good news is that there is still time for healthcare professionals to sign up for the Summit that is being held on June 25-27 in Las Vegas. For registratio, see:

http://taproot.com/summit-single.php

Now is the time to learn practical, proven methods to improve performance and stop the next “medical error” article by eliminating bad practices and implementing good practices.

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No other information will be released prior to the completion of the board’s investigation.

SPARE TIME INVESTIGATIONS

I’ve observed hundreds of companies and found that most incident investigations are carried out by untrained investigators in their spare time.

Even companies that train their investigators to use TapRooT® often assign investigators who already have full-time jobs that keep them busy 40, 50, or 60 hours per week. Where do investigators find the time to investigate? They do it in their spare time!

(Spare time maintenance.)

SOMETHING FOR NOTHING

Managers think they get “something for nothing” when they ask for a quick root cause analysis in the investigator’s spare time. You never get something for nothing. “Spare time” investigations have costs:

- Poor investigations & corrective actions

- Repeat incidents

- Increased risk of big accidents

- Risk of regulatory action after a big accident or because of repeat incidents

- Increased liability when plaintiff attorneys show that management didn’t respond to previous incidents

- Overworked, disheartened investigators

- Investigators trying to dodge investigation assignments

- Disenchanted employees who look at investigations as a waste of time

- Inaccurate investigation statistics

- Loss of management’s faith in root cause analysis

That’s quite a list.

Perhaps economizing on investigations isn’t a good idea.

(Climb the ladder to work on the roof. A reasonable assignment?)

REASONABLE ASSIGNMENTS

If investigating incidents in your spare time is bad, what is a good practice?

A measured response with a wise allocation of resources.

Let’s look at three examples.

Start with a simple incident. A simple investigation by a single investigator is adequate (unless something unexpected is discovered). The key is that the single investigator has to have the time to perform an investigation. Thus, this isn’t an investigation in the investigator’s “spare time.” You must relieve the investigator of his/her normal duties for a period of time. How long? A day or two for most simple investigations.

Next, let’s look at major investigations. Management seldom tries to have these performed in the investigator’s spare time. But, investigators are sometimes pulled away from the investigation to attend to their “normal” work. In this case, a full-time investigation team needs to be formed with an independent facilitator, a full-time team leader, an adequate team (some full-time, some part-time), clerical support, contractor support (specialty analysis and investigation support), and perhaps legal and public relations support. The size of the team and the duration of the investigation depends on the complexity of the accident and the investigation depth requested by management.

In between these two extremes lies the middle ground: investigations that require more than a single investigator but less than a full-blown team investigation. The size of these investigation teams should be based on the incident complexity and the expected return-on-investment of the investigation. Thus, management needs to provide dedicated resources that are proportional to the work and benefits.

HOW MUCH WORK?

For management to assign the appropriate resources, they must know the work required or have an investigation rule of thumb. Unfortunately, many managers haven’t performed a detailed root cause analysis and, because the work required for different investigations is so variable, there isn’t a “one-size-fits-all” investigation guideline for the work required. This means that management will have to start by assigning their best guess as to the required team size and then rely on the investigation team leader to request more support if needed. This won’t happen if team leaders are penalized for asking for help.

Management needs to keep asking, “Is there any help that you need?”

(Benchmarking at the Summit.)

BENCHMARK INDUSTRY INVESTIGATION BEST PRACTICES

Where can management learn more about the resource requirements for investigations and the best practices of industry leaders? At the TapRooT® Summit!

See: http://www.taproot.com/summit

Review the Incident Investigation & Root Cause Analysis Best Practices Track and the Management & Measuring Performance Best Practices Track for details.