January 22, 2020 | Mark Paradies

The Most Important Part of a Patient’s Experience at a Hospital

Improving the Patient Experience

I was reading an article in Becker’s Patient Review about hospital executives’ goals for 2020. There were words such as:

positive patient experience

high-quality medicine with kindness, respect and compassion

a human experience that is caring, safe, effective, affordable and accessible

intentional in our safety and quality work

focused on patient experience

improving the patient experience

I thought…

What is the #1 thing that a patient wants?

The right medical treatment the first time with no complications.

That means NO:

  • Never Events
  • Sentinel Events
  • Adverse Outcomes
  • Wrong-Site Surgeries
  • Misadministered Medications
  • Falls and Injuries
  • Misdiagnosis


Missing the Point

What is the best way to attack and prevent these types of problems that create a negative patient experience?


Not a single executive in the article mentioned that they would be improving their root cause analysis.

And what do we know? That the root cause analysis performed at many healthcare institutions is ineffectual.

How do we know this? Because they keep having repeat never events, sentinel events, adverse outcomes, wrong-site surgeries, …

What is the definition of insanity?

Doing the same thing and expecting a different result.

Admiral Rickover (the creator of the first High-Reliability Organization) said that executives needed to “Face the Facts.”

What is Facing the Facts? Rickover said:

“To resist the human inclination to hope that things will work out,
despite evidence or suspicions to the contrary.”

Without advanced root cause analysis, healthcare executives are hoping that things will work out (a positive patient experience), despite evidence to the contrary.

What is Advanced Root Cause Analysis?

Let’s start out by what advanced root cause analysis is not. It is not…

  • Cause and Effect
  • Brainstorming
  • 5-Whys
  • A Checklist
  • Something that you are doing and it’s not working.

Now that we have that out of the way, what IS advanced root cause analysis?

First, it is a systematic process that can be repeated to produce similar results.

It is explainable. You can show your management how you reached your conclusions.

It has just the right number and kind of techniques needed to guide knowledgable investigators (your investigative team) to the real, fixable root causes of the problem.

It is based on human factors research.

It has been thoroughly tested and proven in a variety of industries (including healthcare).

It is thoroughly documented and has highly rated training to teach the skills needed to your personnel.

It has advanced software to make the system efficient and effective to use.

It has excellent technical support and continuing support for users, including advanced training and a way for users across industries to network and share best practices.

It is being continuously improved using the latest technology and ideas from an extensive user base.

What am I describing? TapRooT® Root Cause Analysis.

We would be happy to explain how we meet each of the goals set out above.

How Can You Learn About Advanced Root Cause Analysis?

There is a NEW course coming up designed especially for those looking to improve patient safety and provide the most positive patient experience. What is it called?

TapRooT® Root Cause Analysis for Patient Safety Improvement

This special course teaches the advanced TapRooT® Root Cause Analysis System for people focussed on improving patient safety.

We noticed long ago (1996), that hospitals weren’t finding the root causes of problems causing patient harm. We knew that the TapRooT® System could help. And we started getting leaders to try TapRooT® Root Cause Analysis to improve patient safety.

Fast forward to 2018. We decided to write a book, Improve Patient Safety with TapRooT® Root Cause Analysis, a custom healthcare-oriented Root Cause Tree® Dictionary, and a course to teach the advanced TapRooT® Root Cause Analysis System to healthcare professionals.

Course Outline

Day 1 (8:00am to 5:00pm)

  • Class Introductions and TapRooT® Introduction
  • TapRooT® System Overview – What you will be learning
  • SnapCharT® Basics – Gathering Information
  • SnapCharT® Exercise – Practice
  • Causal Factors – Identifying the Error
  • Root Cause Tree® – Eliminating Blame
  • Root Cause Tree® Exercise – On Your Own
  • Corrective Actions – Developing Fixes

Day 2 (8:00am to 5:00pm)

  • Software Overview – Practicing the Techniques
  • Generic Causes – Optional Technique
  • Causal Factors – Additional Practice
  • Reporting – Management Presentation
  • Frequently Asked Questions
  • Final Exercise – Putting What You’ve Learned to Work

Now, you can attend a public course with all healthcare-related examples.

Besides saving patient’s lives and preventing harm to the hospital’s staff, what can TapRooT® Root Cause Analysis do for a hospital?

  • Improve hospital financials
  • Reduce risk
  • Improve the quality of care
  • Help create a just culture
  • Reduce financial penalties for bad outcomes (never events)
  • Reduce litigation costs by reducing sentinel events
  • Increase efficient hospital operation

That’s why hospital executives, patient safety leaders, nurses, and doctors need to attend this course.

The course is being taught by experienced instructors Ken Turnbull and Marcus Miller.

Participants will receive the book, Improve Patient Safety with TapRooT® Root Cause Analysis, a $99.95 value, a TapRooT® Root Cause Tree®, a custom healthcare-oriented Root Cause Tree® Dictionary, a Corrective Action Helper® Guide, and a 90-Day Subscription to TapRooT® VI, our dynamic online software that guides you through the TapRooT® process with ease and efficiency.

Don’t Wait and Have a Serious Patient Safety Event

There are over 100,000 (maybe over 200,000) serious patient safety events at hospitals throughout the USA. Canada, Australia, and the UK aren’t any better. There is a need for serious improvement. We have helped clients in industries around the world stop serious incidents by learning from their operating experience using the TapRooT® System. We would love to help you achieve your patient safety goals and send your patients home delighted with an event-free experience.


Don’t wait to register. Seats are limited in this course and because it is the first course we’ve offered to the public, it will fill up fast.

Register for TapRooT® Root Cause Analysis for Patient Safety Improvement Course AND the 2020 Global TapRooT® Summit (March 9 – 13, 2020).

Register for just the 2-Day TapRooT® Root Cause Analysis for Patient Safety Improvement Course (March 9 – 10, 2020).

Courses & Training, Patient Safety & Healthcare, Root Cause Analysis, Summit
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