Category: Medical/Healthcare

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.

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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

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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

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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
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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.

A Dose of Healthcare Humor

February 26th, 2016 by

Although technology has made medicine better and more consistent, this is probably something you never want to hear your doctor say.

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Is it time for your healthcare facility to make an investment in root cause analysis?  Learn more about getting a better ROI here.

Can the Cause of a Surgical Error be the Same as the Cause of an Oil Spill?

February 18th, 2016 by

This article raises a very fundamental question, are industries different when it comes to the causes of accidents? And even simpler, are job functions so different that they cannot have similar issues or problems?

Before we discuss this issue I want to start with a personal story. Many years ago I was giving a talk on Root Cause Analysis to a group of Physicians for a health system in Florida (about 50 if I remember correctly). The questions and discussion from the group had worked its way around to the difference in classes (jobs) within a hospital and the types of mistakes that are made. Understanding Human Performance as I do, I made what I thought was a simple statement of fact (and I quote),

Doctors and janitors make mistakes for the same reasons.

After the blank stares turned to surprise, contempt, then anger, I am sure you know the response I received. Later, once I escaped the room and was safely on a plane home, I thought about the reaction and came to the following conclusion. People truly believe that their job is different, different from any other, more important and difficult than any other. Is this perception? Or is this reality? Let’s find out …

Now, on the surface, I believe most people would say the answer to the question “Can the Cause of a Surgical Error be the Same as the Cause of an Oil Spill?” will be a stern “No”. The widely-held belief is that the causes of these two issues have to be different. A surgical error made by a physician or nurse in a surgical suite has to be different from the errors made by a highly skilled tradesman causing an environmental release. They appear as different as night and day until you dig down deep into Human Performance and realize that both situations hinge on similar human factors. Let’s begin this search by looking at these two events along with causal factors for each:

Our Sentinel Event is: Surgery is performed on the wrong patient

Our Spill accident is: 500 gallons released environment

Here are a couple of causal factors, one for each. Looking at these two different situations do you see any similarities?

Policy Violation

Both of these causal factors, although from different industries and different situations and job types, have similar causes to them. Both deal with Management System->SPAC Not Used->Enforcement NI. Both situations show a series of behaviors that have not been addressed or fixed by supervision or management, that have happened multiple times and have become common practice. Looking at our Root Cause Tree® Dictionary, we would get a yes to the following question in the Enforcement NI Definition for both:

  1. Has failure to follow SPAC in the past gone uncorrected or unpunished?

I think that shows that both of these situations have common systemic problems that have led to similar behaviors. There may also be other root causes based on other causal factors and other conditions presented here. But there is at least one common thread above.

One more example from the same incident, here are two additional causal factors:

Labels

Again, both of these deal with misidentification of a critical part of the system, one the patient receiving surgery and one a valve in a process. Now before I get emails saying that you can’t equate a human life to a valve, I understand that point and that is not what I am doing. I am simply showing that the quality of the “label” used to ID something (no matter what it is) can impact the end result. There are also other root causes here that may be different based on the data presented, but there are similar Human Factors that apply to both.

And just to make sure you understand the label in the industrial example used, here is the font and the label used:

Valve Label Font
See any issues here????

So in the end, no matter what you do for a living, no matter how educated or experienced the person is, mistakes happen because of Human Performance based issues. The same issues affect us all no matter how different we believe our systems can be. This is exactly why our system is based on Human Performance and Equipment Performance principles and not based on industry variables and conditions. Our TapRooT® system has been proven to work in any industry equally as well. The only limitation that is put on the use of TapRooT® is the one we impose on ourselves based on our own professional bias.

If you would like to learn more about how TapRooT® can work in your industry please feel free to contact me at skompski@taproot.com or attend one of our public seminars. Our courses can be found at www.taproot.com/courses.

Undervaluing Root Cause Analysis in Healthcare

February 12th, 2016 by

ROI-Button

Is RCA, its Return on Investment (ROI) and its impact within healthcare undervalued?

Read an article this past week discussing a hospital system investing $55 million to implement an EHR platform to improve efficiency within their hospital system (15 counties across all hospitals, offices and outpatient care facilities). They stated that the $55 million would be recouped by efficiency within 6 years of implementation. My first thought was, “Man that is smart”, being able to recoup almost $10 Million a year that is good business. Then the investigator in me thought, “Why don’t healthcare companies view RCA the same way?” Interesting question isn’t it? Is RCA, its Return on Investment (ROI) and its impact within healthcare undervalued?

Every healthcare professional understands the risks involved with patient treatment and patient care. These risks many times manifest themselves as Sentinel Events which are required to be analyzed through to Root Cause, and associated corrective actions. These are very visible issues that not only are known to the hospital but to the neighboring communities (at a minimum in today’s fast paced social network society).  Doing some research I found some very interesting numbers provided by various sources that made me think, are we undervaluing the ROI from good root cause analysis of Events and issues in Healthcare.

From the Sentinel Event Alert #55 issued in Sep 2015 the following data on falls in healthcare is provided:

  • Since 2009 there have been 465 reports of falls with injury (Sentinel Event Database)
  • 63% of these reported falls (Sentinel Event Database) resulted in death
  • The average cost of a fall with injury is approximately $14,000 (Industry research)

The alert above did not provide the cost of an actual fatality related event, but from general industry research that provided data over multiple industries (NIOSH) the average cost of a workplace fatality is approximately $944,000 dollars including all associated costs. I am not equating the two costs to be equal, but for this discussion I would believe this number to be commiserate with costs in healthcare for a Sentinel Event related fatality if you include damage to reputation, legal fees, compensation, and lost future business (to name a few).

So doing some basic math, over the time of this study the cost to healthcare organizations for reported patient falls would be:

  • 63 * 465 = 293 fall related deaths
  • 465 – 293 = 172 falls with injury
  • 172 * $14000 = $2.41 Million
  • 293 * $944000 = $276 Million

Total $278.41 Million

So reported falls with injury or fatality to TJC cost the healthcare industry approximately $279 Million dollars from 2009 to the present. The numbers when calculated across all Sentinel Event types are staggering. So by performing a very simple cost analysis, I believe it would be fair to say that stopping these types of events would be of value to any healthcare organization. So why are we failing? Why are we not investing more into these RCA systems and education to see greater returns?

Through years of talking and working with healthcare professionals I have heard the following:

  • It is hard to put a cost on what has not happened
  • Being both a Risk Manager, Patient Safety Manger and wearer of many hats I don’t have time to analyze everything
  • We are only required to analyze Sentinel Events
  • Healthcare is a very complicated process with many inherent hazards, things just happen
  • We are performing well above average as compared to the healthcare industry
  • We in healthcare can’t be compared to other industries… we are different
  • RCA training and processes are too expensive when I get these tools for free

Although many of these statements are at their core true, the idea that “things just happen”, or that “we are different” in my mind are not reasons, they are excuses. A harsh answer I know but that is the reality I see. If failure is considered acceptable then I can certainly understand why money is not put into effective RCA and tools for better corrective actions.

But if I look at the cost of one fall with injury (not even a fatality), I believe that there is a very good justification for a better investment into your RCA. I will use the cost I am familiar with which is the cost of our public 5-day training. One seat at a TapRooT® 5-day Course (includes Software) is $2895. You invest that money, produce a high quality RCA including measureable and trackable corrective actions and prevent 1 fall with injury ($14000), you have an ROI of 3.84 on your investment immediately.

I know that your administration might not be impressed by saving $14,000, but an ROI of 3.84 is incredible! And extrapolate the $14,000 savings out across all the Sentinel Events, or the incidents that have a high potential risk, and the possible savings from a pure cost savings could be huge. And the return is not 5 to 6 years away… it is almost immediate. Reducing your rate of falls, or medication errors, or any other Sentinel Event type by even a small percentage can show an IMMEDIATE return on that investment. Having multiple people trained and experienced in your RCA program simply becomes a multiplier towards that ROI and the improvements to Patient Safety and lowering risk.

The old saying, “Getting out what you put in” is very true when it comes to your RCA program. Don’t undervalue the impact of what a bad RCA is costing you and prove what good RCA tools can save your organization immediately. If you provide your employees with the best tools, the right level of training and knowledge, and put those tools to work, there will be a return on that investment for both your organization and for your clients/patients. If you have any questions about improving your RCA program please contact me at skompski@taproot.com or call me at 865-539-2139.

What Does a Generic Cause Look Like in Healthcare?

February 5th, 2016 by

I have been teaching RCA now for almost 20 years and have found that Generic Cause is many times the simplest yet most confusing step in our RCA process. The first 4 steps from Getting Started (reporting) through Root Cause Analysis (Root Cause Tree®) move very efficiently. But transitioning from “Specific” root causes linked to Causal Factors to “Generic” causes that tie multiple events together seems to trip up many professionals.

7-step Investigation Flow
I found an interesting article that can be found HERE, that provides a very good example of a generic cause.

What is a Generic Cause?

First let me start with a quick discussion of our philosophy on Generic Cause. Step 5 in the process flow above addresses this issue prior to developing your Corrective Actions. We need to first understand the “Specific” root causes from Step 4, and the “Generic” causes before we begin developing Corrective Actions so both can be addressed.

The definition of a “Generic” cause in our system is as follows:

The Systemic problem that allows a root cause to exist, across multiple incidents or sites or systems.

This is a bigger picture issue that is allowing the same root causes to exist across multiple events. So that being said, let’s dig into the article above to provide a description of a “Generic” issue.

The Duodenoscope Example

The article discusses a particular type of duodenoscope produced by one manufacturer used across the healthcare industry. This particular scope had been linked to multiple cases where infection had been spread to patients. So similar infections, when investigated by individual hospitals, provided data showing that this particular type of scope was involved. Breaking down that statement, we have the following:

  1. Same brand and model duodenoscope
  2. Used in multiple facilities over a term of 5 years
  3. Multiple instances of infection transmission following use of this scope

Are you seeing the pattern in this list? Something is similar in all these instances… the scope itself. Now, from the article (which does not provide any RCA data), I can only speculate on the Root Causes for this “spread of infection” as it relates to the scope… from the Corrective Actions taken by the manufacturer it looks as if there could be any of the following issues:

. . . A. Equipment Difficulty->Design->Specs NI
. . . B. Equipment Difficulty->Preventative/Predictive Maintenance-> PM NI-> PM for Equip NI
. . . . . .1. If you assume the cleaning procedures and recommendations to be Preventative Maintenance
…………..on the scope
. . . C. Human Performance->Procedures->Wrong->Facts Wrong
. . . . . .1. If here you assume the cleaning instructions are procedures and they did adequately provide
…………..information on cleaning the scope.

Any of these could relate back to the Corrective Actions which include the recall, a redesign of the scope as well as changes to the cleaning requirements.

Finding Generic Causes in Your Organization

Now looking at these causes, and the list of items that meet the definition of a Generic cause, I have to ask everyone reading this article:

How would you as an organization know that you are having Generic problems?

The answer to that question will probably vary from organization to organization but there is probably one key element. That key element is consistent Classification of events, consistent Root Cause Analysis, linking your Causal Factors (on the Causal Factor Editor) to specific Equipment types and Departments, and effective trending and data analysis. Without a clear, well defined classification schema for all investigations or incidents within a healthcare facility/system it would be nearly impossible to trend your RCA data and determine where similar causes and events are happening.

Once you get a standard Classification list together, and consistently classify your events, you can now perform a couple of different Trending functions (from the TapRooT® Software v5.3) to determine Generic Causes:

  1. Search your data using our Root Cause Distribution Report by filtering Classification and over a date range to see all causes produced. If you find a particular root cause across those RCA’s you may have a generic cause.
  2. Run a Pareto Chart using Equipment as your X-axis and Counts as your Y-axis on the chart to look at counts. See if one piece of equipment is linked to 70-80% of your causes… this might give you a clue to a Generic Issue
  3. Run a Process Behavior Chart looking at a Specific Classification, and run an “Instant Rate” chart or an “Interval Chart”. These would cue you in on if your rate of failure is increasing or if your time between occurrences is decreasing respectively and may provide some insight into your overall Equipment or program health.

If you have any questions about Generic Cause or any additional Trending functions please feel free to contact me at skompski@taproot.com

Expanding the Scope of RCA in Healthcare

January 25th, 2016 by

doctor-563428_1920Read a recent article and it referenced something that I have been preaching for years regarding health and safety. It is probably not what you think.

For many years, the culture within healthcare has been focused on reducing medical errors, minimizing impact on the patient through sentinel event analyses, performing proactive analyses on high risk processes using FMEA and raising awareness about risk reduction and patient safety.

All of these efforts have huge merit and a very high visibility within and outside of the healthcare community. When we enter a hospital we (as clients and patients) have the expectation to leave in better shape than we arrive. We certainly do not expect harm to come to ourselves or our loved ones but when things can and do happen the expectation is that the organizations will learn and improve. Thus resources and money are applied to the RCA programs around these visible events.

So with all these programs and efforts put towards the “clients” within healthcare I have always wondered, “Are there resources or efforts left for workplace safety within healthcare?”.

The article on “10 top safety issues for 2016” by Becker’s Infection Control and Clinical Quality Newsletter brought this thought back to me by listing the following 2 items as risks towards Patient Safety:

1) Workplace Safety, focused on the safety of healthcare workers
2) Hospital Facility Safety, focused on building or maintenance type issues

When I read the entire list it was so in line with our philosophy on the impact of systems and the workplace on healthcare professionals themselves. When we think of performing root cause analysis we think of problem solving, fixing what was wrong by implementing corrective/preventative measures and thereby creating a safer environment. If we create a safer environment for those who work in a healthcare setting, our caregivers, wouldn’t we also be creating a safer environment for patients and visitors within the same framework? I believe so.

One of the first principles we teach in all of our TapRooT® training programs involves defining the “incident” or in healthcare terms the “Event.” This becomes the circle on our SnapCharT® and by its nature is the focus of the investigation and the issue or occurrence we want to prevent in the future. The incident can be ANY problem you wish to solve, ANY adverse event or occurrence needing evaluation… it does not have to solely sit at the top of the Patient Safety or Risk hierarchy.

Let’s take a quick quiz, here is the question:

Which of these issues could be investigated using the TapRooT® Methodology?

A) Medication error resulting in long-term harm to a patient
B) Nurse strains their back trying to reposition a patient causing lost time
C) Patient spouse slips on a loose tile in the main hallway outside the Pharmacy
D) Hospital administrator slips on water leaking from the fire system in admin wing
E) Backup generator does not start in time to provide uninterrupted power
F) All of the above

Well what do you think?

If you answered “F – All of the above” you are correct! All of these problems or issues can cause adverse impact to your organization. All of these problems can cause a cascading effect on both patient care as well as employee safety.

The TapRooT® process has tools and a language that fits all these situations without having to change your RCA approach or methodology. The same thought process applies to both the clinical and non-clinical issues facing your organization. The 7-step Process Flow used in the Sentinel Event training course is the same that we use in our Equifactor® (Equipment Troubleshooting) training course, as well as our public RCA seminars. Human Performance and Equipment performance are the same from the investigative perspective no matter what the problem you are trying to solve.

So as we enter 2016, I want you think about others inside your organizations outside of the clinical organizations that can benefit from the same tools Patient Safety and Risk Management use in TapRooT®. Maximize your use of the process to maximize your return on investment in training… your facility maintenance personnel, your facility administration personnel… anyone who is tasked with problem solving and troubleshooting can benefit as well. Create a safe work environment for those closest to you (your employees), and you also create a safer environment for your clients (patients and our loved ones).

If you would like information on our training courses for Root Cause Analysis, Equipment Troubleshooting, Evidence Collection or any other TapRooT® courses please contact me at skompski@taproot.com or call me at (865) 539-2139. I would love to help you create the total environment for patient care.

Medical Humor May Explain Difficulties in Root Cause Analysis

January 14th, 2016 by

Found this cartoon and truly laughed out loud (or as the Millennials put it, “LOL” or “Hahaha”). Working with healthcare has truly shown me the complexity of the business including making very educated judgments in a very complicated environment (physical and physiological). I thought this might just provide our healthcare TapRooT® users a respite from an otherwise serious job… and maybe a few interviewing questions to boot when performing the next RCA… such as “did the patient have 100+% limbs?”

watson_medical_algorithm

What do you think? Leave your comments below.

 

How Can TapRooT® Help Prevent Falls and Maintain a Fall Prevention Program?

January 7th, 2016 by

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While reading Sentinel Event Alert 55 (SEA-55) from TJC issued September 28, 2015 on Fall Prevention, it occurred to me that TapRooT® can be used to aid in finding the root causes of the fall. Even more importantly, TapRooT® can be used to aid in maintaining your fall prevention program to ensure long-term success. The TJC lists the following common contributing factors (in TapRooT® these would be called “Causal Factors“):

  • Inadequate assessments
  • Communication Failures
  • Lack of adherence to protocols and safety practices
  • Inadequate staff orientation, supervision, staffing levels and skill mix
  • Deficiencies in the physical environment
  • Lack of Leadership

While these are good guidelines for what to look for and what data to gather, to us these do not represent root causes. These 6 items almost match up with most of the 7 Basic Categories on the back of our Root Cause Tree®. So as TapRooT® investigators, know you have to dig a bit deeper to find the true causes and define those at the Root Cause level not at the causal or contributing level.

All this being said, the more important reason I wanted to write this article is to highlight the use of your TapRooT® tools by using them for Proactive measures. How to examine and improve your fall management program and maintain continued success. Too many times we don’t think about the power of observation and the idea of raising awareness through communication. Each of these can be highlighted through the Proactive Process Flow below:

ProactiveFlow

In SEA-55, two of the actions suggested by TJC were to 1) Lead an effort to raise awareness of the need to prevent falls resulting in injury and 2) Use a standardized, validated tool to identify risk factors for falls. These two items can benefit from the TapRooT® tools directly.

Starting with step 1 above in the Proactive Flow, use the SnapCharT® tool to outline the steps in patient assessment, highlight the steps that can or will affect the fall prevention portion of patient care, then use this flow as the basis for an observation program. By getting out and observing actual performance in the field you can do two things, show your concern for patient safety (and falls in this case) and gather actual performance data. These observations can be performed both in a scheduled and/or random fashion and can be done in any setting (ambulatory, non-ambulatory, clinic et cetera).

During the observation, document findings on the SnapCharT® and identify potential “Significant Issues” as they apply to fall prevention. This data can then be either evaluated using the Root Cause Tree® to define the areas of need for that single observation, or the data can be combined with other fall prevention observation data for use in an aggregate analysis or common cause analysis. With the aggregate analysis data from multiple observations can be combined, and “Significant Issues” can be identified based on multiple observations before an analysis using the Root Cause Tree® is performed. This could give you an overall bigger picture view of your processes.

Once the RCA is performed (in either situation), Steps 5-7 can be simply followed to produce some recommended actions to be implemented and measured using Corrective Action Helper® and SMARTER. And the beauty of this Proactive process is that you have not waited for a fall to learn.  You and your organization are preventing future issues before they manifest thus showing your patients and staff that you truly care about their safety.

If you would like to learn more about using your TapRooT® tools proactively you can contact me at Skompski@taproot.com for more information or you can attend any of our public seminars, 2-day or 5-day to learn more on both the reactive and proactive use of the TapRooT® tools!

Healthcare and the 3 Standard Corrective Actions

December 30th, 2015 by

 

Are you asking these two questions?

Are you asking two questions?

In all industries people struggle to create effective, measurable corrective actions. Many times we fall back to our standard ways of thinking and do what has been comfortable no matter the effectiveness we have seen in the past. In our courses we discuss the three “Standard” corrective actions:

  1. Training. Retrain everyone, not just those involved.
  2. Policies/Procedures. Write new policies or procedures or make the current ones longer.
  3. Discipline. Send a message to everyone else that a behavior is unacceptable whether or not there is fault.

When these are the standard actions, many times we have recurrence of events. I am not saying these actions can’t work, but many times if they are default answers it is much like putting a round peg in a square hole.

In this article a hospital in Hong Kong presents an overview of their findings and recommended actions to a Sentinel Event at the hospital. Review the Corrective Actions and ask these two questions:

1. Do they meet the needs of the system based on the findings? 

2. Do you see a correlation with our three standard corrective actions above?

Maybe there is a pattern… let us know your thoughts.

Why Healthcare Root Cause Analyses Fail

December 16th, 2015 by

medicine-91754_1280

For many years now the TJC and other governing bodies have required root cause analysis (RCA) on Sentinel events as well as analyses on near misses with high potential. To remain accredited, organizations have put together teams to perform analyses to find the causes and to recommend, implement and track corrective actions. Throughout this time of focus and effort there continue to be repeat sentinel events. So the question that arises is, why are these RCA’s failing?

This question may appear very complex but the root of the problem is actually very simple. From reading many Event reports and examining how many organizations perform these analyses two things stand out to me:

  • Many analyses stop at too high a level due to a lack of information and do not reach true root causes. They stop at what we define as a Causal of Contributing factor.
  • Many corrective actions don’t address the root cause due to the limited analysis or because the corrective actions created are not specific to changing a particular behavior or system.

What truly makes this even simpler is the fact that these two issues are interrelated. If you don’t thoroughly gather the correct information and identify the true root causes the corrective actions may not be focused enough to fix the problem. We will then fall into the trap of implement general or employee focused corrective actions that don’t address system problems. This can result in wasted time and resources and can have a very negative impact on the people involved in the event.

Here you see an example where the investigator stopped gathering data at a Causal or Contributing Factor.

CFOnly

In this example there was a mistake made by the nurse when retrieving a medication for a particular patient. With no additional information gathered, the investigator is forced to stop at this level. No more analysis can be performed without many assumptions and opinions being used. In this case, when the team moves to corrective actions, how do you fix someone retrieving the wrong medication? Well, without any additional information, we counsel the employee to be more careful, we punish the nurse for making the wrong choice, and/or we retrain everyone to make sure there is an overall understanding of this issue. None of these truly change the system and address the causes of the issue (as you will see below).

If the investigator gathers much more information on the issue there is at least a chance to more thoroughly examine the issue using your RCA tools and dig deeper to a root cause level.

FullInvData

Having this additional data available allows the investigator to dig deeper into the issue to identify the underlying system root causes that contribute to this mistake by the nurse. This changes the focus to the organizational systems and not solely on the individual. Knowing that it has become common practice during high census to not follow the second check rule (or 5 Rights) and there have been no negative consequences consistently provided by management for this issue we would be able to identify system related causes such as Management System ->SPAC Not Used ->Enforcement NI (from the Root Cause Tree®) and other causes. By getting to this level of analysis and understanding the system cause(s), we can now build corrective actions to address specific system issues. By addressing the specific causes and in this case changing the rules or terms around times with a higher than normal census, the requirements for following and consequences for not following this policy we are changing the systems in the organization. By changing the systems we can enact long lasting positive change in the organization and build sustained success and change the behaviors of our employees.

Learn more about TapRooT® here or contact us to find out how TapRooT® is the answer to succeeding in your healthcare root cause analyses.

Friday Joke: Not Encouraging

November 27th, 2015 by

A man was seen fleeing down the hall of the hospital just before his operation.

What’s the matter?” he was asked.

He said, “I heard the nurse say, ‘It’s a very simple operation, don’t worry, I’m sure it will be all right.

She was just trying to comfort you, what’s so frightening about that?

She wasn’t talking to me. She was talking to the doctor.

Did you know it is “International Clean Hands Week”?

September 22nd, 2015 by

NewImage

Henry the Hand brings you the “T Zone Teaching Moment.”

Here is the video …

Visit this web site for more information:

http://www.henrythehand.com/healthful-tips/t-zone-teaching-moment/

Product Safety Recall…… one of the few times that I see Quality and Safety Merge

June 22nd, 2015 by

We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine….) or recalls that may be impacting us today (air bags). These recalls all have a major theme, a company made something and somebody got hurt or worse. This is a theme of “them verses those” perception.

Now stop and ask, when is the last time quality and safety was discussed as one topic in your current company’s operations?

You received a defective tool or product….

  1. You issued a defective tool or product….
  2. A customer complained….
  3. A customer was hurt….
  4. ???….

Each of the occurrences above often triggers an owner for each type of problem:

  1. The supplier…
  2. The vendor…
  3. The contractor…
  4. The manufacturer….
  5. The end user….

Now stop and ask, who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development or corrective action implementation?

This is where we create our own internal silo’s for problem solving; each problem often has it’s own department as listed in the company’s organizational chart:

  1. Customer Service (Quality)
  2. Manufacturing (Quality or Engineering)
  3. Supplier Management (Supply or Quality)
  4. EHS (Safety)
  5. Risk (Quality)
  6. Compliance (?)

The investigations then take the shape of the tools and experiences of those departments training and experiences.

Does anyone besides me see a problem or an opportunity here?

What is the burden of unsolved problems at your company?

May 4th, 2015 by

Do you have incidents that happen over and over again?

Do you have repeat equipment failures?

Does your hospital have similar sentinel events that aren’t solved by your root cause analysis?

How much are these repetitive problems costing your company?

Stop making excuses and try something NEW that can help you stop repetitive problems…

IDEA #1: Attend at TapRooT® Course to stop repeat incidents.

Choose from the:

These courses are guarantee to help you find root causes that you previously would have overlooked and develop corrective actions that both you and your management agree are more effective.

IDEA #2: Attend the Creative Corrective Actions Course.

Hurry, this course is only offered on June 1-2, prior to the TapRooT® Summit. If your creativity for solving problems is getting stale, this is the course you need to attend.

IDEA #3:: Attend the 2015 Global TapRooT® Summit in Las Vegas on June 3-5.

The Summit is a proven place to network and learn valuable best practices that can help you solve your toughest problems. Each Summit is unique, so you don’t want to miss one. And this year’s Summit is rapidly approaching. Register today at:

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

Southlake Hospital Staff Lives Their Values

March 24th, 2015 by

Michele Lindsay, President of Performance Potential Inc. and member of the Quality and Risk Department at Southlake Hospital recently shared this awesome video with us. Join Michele at the Global TapRooT® Summit June 1 and 2 for her exclusive 2-Day Creative Corrective Actions Course and sign up for the Improving Healthcare and Patient Quality track June 3 – 5 to attend her best practice session, RCA of Multiple Events, which is a case study of performing root cause analysis on several incidents that appear to be related. Take the opportunity to learn from many incidents that may not trigger a root cause analysis on their own, but collectively provide significant insights into process and system weaknesses so effective corrective actions can be put in place.

Hope you enjoy the video! Learn more about the 2015 Global TapRooT® Summit at:

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

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