Celebrate Patient Safety Awareness Week: Implement Continuous Improvement Investigations
We’re celebrating patient safety awareness week while putting the emphasis on furthering “safety” through continuous improvement investigations (more about this in a second).
As we celebrate patient safety awareness week, it’s appropriate to evaluate how patient safety investigations are conducted and how we can improve investigations to protect patients from harm.
Continuous improvement should be the result of your investigations.
You will see less severe events over time if your investigations are leading to continuous improvement. Every investigation should lead to improvements that support our healthcare workers and improve patient safety.
Spotlight for Patient Safety Awareness Week: What needs to happen for EVERY investigation to lead to continuous improvement?
1. The investigation process needs to be standardized.
Ask yourself, Do we have investigators that get better results than other investigators? If the answer is yes, then you have room for improvement. Patient safety should not be left to chance. You can overcome this challenge easily. The organization needs to provide and train investigators on a standardized investigation process that provides tools that close the gap between the individual investigator’s expertise and experience. The goal should be: no matter who does the investigation, as long as they follow the process and use the tools provided, they will identify the same root causes of the safety event. An easy test to see if this is an issue is to give two or three investigators the same event to investigate. Do they come up with different root causes? If so, you have room for improvement.
2. The investigation needs to have a well-established process for gathering and documenting evidence.
Ask yourself this question to determine if there is room for improvement: Do you hear people second-guess the findings of the investigations and the effectiveness of the corrective actions? If you do, then the investigators didn’t have a good way to show the correlation between the evidence they gathered and how it was used to diagnose the root causes that contributed to the event. If they can’t prove that link exists, then their findings are NOT defensible to leadership, regulatory agencies, or the patient and their families. Investigations need to be evidence-based, not based on cause-and-effect processes such as 5-Whys or Fishbone.
Read Mark Paradies’ illuminative post on the fundamental problems with 5-Whys, “What’s Fundamentally Wrong with 5-Whys?”
3. The investigators need a tool that allows them to analyze problems and find root causes just like a human performance expert would.
Not all of us are human performance experts but in order to properly diagnose the root causes that lead to patient harm, you need strong human performance knowledge. Root causes are only the absence of a best practice or the failure to apply knowledge that would have prevented the patient safety event.
When you identify a root cause, you are effectively finding system weakness. These weaknesses either allow the mistake to be made in the first place or the weaknesses don’t catch the mistake before it causes harm. Investigators need human performance expertise to identify and fix system weaknesses so the people who care for patients are better supported. A good test to see if investigations are leading to the true human performance root cause is to ask, Do our corrective actions focus on:
- Retraining people?
- Disciplining people?
- Rewriting or adding to policy and procedures already in place?
If so, your investigations are only determining who made the mistakes and corrective actions are mostly focused on blame. I know that sounds harsh but think about it. If you are retraining people who have already been trained, you are blaming them. If you are punishing people for making mistakes, you are blaming them — especially if they were working under stressful or difficult circumstances.
You know about a typical day in healthcare. If you are adding to already established policy and procedures because you think someone couldn’t or wouldn’t follow them, you are blaming them. Without giving the investigators the necessary tools for proper root causes analysis, your corrective actions will allow repeat harm because they are not fixing the true human performance root causes. The corrective actions are focused on fixing people and not the systems that are supposed to support our healthcare workers. I’m not saying there isn’t a place for those type of corrective actions if needed but, if they make up a good portion of your corrective actions, you have room for improvement.
4. The last thing I would like you to analyze are the tools your patient safety investigators have to create more effective corrective actions.
Since root causes are only the absence of a best practice or the failure to apply knowledge that would have prevented patient harm, corrective actions should simply introduce the missing knowledge or best practices into the systems that support our healthcare teams and protect patients.
Ask yourself, Do the investigators have a database of knowledge or best practices they can easily pull from to create more effective corrective actions that will keep patients safe? If no, you have room for improvement.
- We provide a way to gather and document evidence.
- We provide a way to analyze the evidence so you find the mistakes that led to an event.
- We provide RCA tools based on human performance expertise so the true root causes of problems are identified.
- And we provide a database of proven best practices and ideas that the investigators can borrow from when creating corrective actions.
If you are curious, email me and I can provide a simple demo to help you determine if TapRooT® can help your teams continuously improve your patient safety outcomes with every investigation: email@example.com.
Patient Safety Awareness Week: What can TapRooT® RCA do for you?
I have served as the vice president of operations in the healthcare industry and, through TapRooT® RCA, I am committed to improving the safety of workers and patients by meeting the challenge of the lack of comprehensive root cause analysis in the healthcare industry.
I’m happy to be your TapRooT® contact to discuss root cause analysis, investigations, training, or any questions you may have: firstname.lastname@example.org.
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