Critical Event Review(Root Cause Analysis)

Hutchinson Area

Health Care

December 2008

What are we going to cover?

• What is Critical Event Review (CER)? – Brief Overview

• Reasons for conducting a Critical Event Review

• Hutchinson Area Health Care’s use inLong Term Care - Process

• Story

What is a Critical Event Review?

• A process that uses a systems approach for identifying the basic causes for an undesirable event or problem

• Focus on the process and systems, not individuals

• Uses the technique of asking the “why” question multiple times

• A confidential process

Reasons to do a Critical Event Review

• It is a review process used to uncover the facts and the underlying story that led up to the event– Identification of contributing factors– More in-depth understanding of the sequence of events

• Assists in improving facility systems/processes

• Promotes proactive Action Plan development to assist in preventing recurrence

• Resident Safety– Reduce the harm to residents by increasing the

resilience of our responses when the event repeats

Events where use of CER could be considered…

• Events with serious outcome for the resident

• Repeating incidents

• Near Misses/Good Catches

• Examples: – Falls

– Medication Errors

– Plan of Care not followed

CER Selection Criteria

• Initially Joint Commission driven – Sentinel event standard requiring RCA’s to be done

• Was applied to CMS sentinel event criteria• Based on event data analysis

– Highest event (falls)

– Severity

• Resident safety focus – reduction of harm • Future – working to be proactive – near miss

Immediate Actions• Ensure resident and staff are safe

• Notification of Administration

• Assess need for additional resources

• Secure equipment, tubing, medications, involved in event

• Communication to resident and family

Immediate Actions (continued)

• Complete documentation by the care provider– Medical Record: Facts- Objective data/description of

event– Event/Incident Report

• Institute an immediate corrective action if possible

• Staff Notes (not part of the medical record)– Coach staff: record when resident last seen, what they heard, room

arrangement, location of equipment, your response – Who, What, When, Where, Why– Staff notes need to turned into

Quality Department or Quality Manager

• Drawings/Pictures

CER Meeting Steps

• Set up initial meeting 48 to 72 hours post event (if not sooner)– Who sets up the meeting

• Identify and invite key players• Won’t compromise resident safety

Key Players• Staff from departments/units directly and

indirectly involved in the event

• Nursing Administration

• Medical Director– Physician/Provider as needed

• Quality Representative

• Administrator

• Facilitator

• Others as identified

CER Meeting Steps (continued)

• Coaching Staff – May be initiated prior to meeting being set up

if member has not participated before• Participation in the CER is an opportunity to learn

• Chance for staff to tell their story

• Emphasis is on improving the system

• Just in Time Training

Meeting Preparation

• Room with comfortable atmosphere

• Flip Chart and Markers

• Kleenex

• Coffee/Water/Treats

• Medical Record/Reports

• Any of the pre-work documentation– Staff Notes– Chart Review

• Lead nursing completes

– Time line of the event

Facilitator • Team training/group skills

– Clinical background can be helpful, but not required– Listening skills – use facilitation to uncover the story

behind the event– Analytical skills – conversational/timeline versus

investigation data gathering

• Positive – sense of humor – sensitive – deal with emotions – awareness

• Strong boundaries– Brings people back to focus– Ability to manage emotion at the table – fear/anger– Is able to identify and draw out people– Engages the entire team to give their perspective

• Need to support everyone’s style

Recorder

• Recorder – listen to how they are saying, as well as what they are saying– Facilitator may be the recorder as well– Would recommend a recorder be available

Meeting Format

• Introductions and Ground Rules – Confidentiality– Titles left at the door - all members need to be

active participants– There are no bad questions– Systems and process focus

• Not blaming/finger pointing

– Want to foster creativity • “You” have the solutions

• Brief orientation to CER

CER Meeting in Progress• Tell the story• Brief overview of resident• Start with the person who found resident

• Try to obtain details of what happened

• What did you see?

• Encourage people to share • Facilitator stands in front and captures data on white flip chart

– “BIN” list – gives credence, but allows facilitator to move back to subject

• Try to identify opportunities /gaps as the story is presented

• Why, Why, Why?– How were they laying? Where was the wheel chair?

– What is the purpose having the wheel chair across the room?

Use of Triage Questions

• Helps team understand event• Assures thoroughness of investigation –

“buckets”– Human factors

• Staffing– Communication/Information– Equipment/Environment– Uncontrollable external factors– Training– Rules/Policies/Procedures– Barriers

Forms

CER Meeting cont.

• Identification of factors that may have influenced the circumstances that led to the event– Identification of system/process gaps– Opportunities identified for improvement

• Feedback from participants on how systems can be improved is critical– Is there anything that we could have been done differently?

• Development of an action plan – based on findings – with target dates and responsible party listed– Monitoring/measurement plan as indicated– (Critical Event Review Corrective Action Plan -to be covered more in depth in later

presentation)

• Follow-up

Spread the Success/knowledge

• Share with staff and Administration– Need to go beyond interdisciplinary care team

• Potential: – Share learnings and collaborate with other

facilities

Critical Event Review Summary

• To be thorough, a RCA must include:

– Determination of human and other factors– Determine related processes and systems– Analysis of underlying causes and effects –

series of why’s– Identification of risks and their potential

contributions

Questions?

Thank you!