Root Cause Analysis and Improvement in the Healthcare Sector : A Step-By-Step Guide.

By: Andersen, BjørnContributor(s): Fagerhaug, Tom | Beltz, MartiMaterial type: TextTextPublisher: Milwaukee : ASQ Quality Press, 2010Copyright date: ©2009Description: 1 online resource (256 pages)Content type: text Media type: computer Carrier type: online resourceISBN: Subject(s): Medical care -- Quality control | Medical errors -- PreventionGenre/Form: Electronic books.Additional physical formats: Print version:: Root Cause Analysis and Improvement in the Healthcare Sector : A Step-By-Step GuideDDC classification: 610.28/9 LOC classification: R729.8 -- .A53 2009ebOnline resources: Click to View
Contents:
Intro -- Title page -- CIP data page -- Table of Contents -- CD-ROM Contents -- List of Acronyms -- Preface -- Chapter 1 Root Cause Analysis in Healthcare -- All Organizations Have Problems-Why Is RCA So Important in Healthcare? -- Brief History of RCA in Healthcare -- Definition of a Problem -- Different Levels of Causes -- The Nature of Variation -- Root Cause Analysis -- Related Tool, Processes, and Systems -- System-Level Impediments to Effective RCAs -- Person-Level Impediments to Effective RCAs -- Practice-Level Impediments to Effective RCAs -- Chapter 2 The Root Cause Analysis Process -- The Root Cause Analysis Process -- Explanation of the Table -- Examples -- Full Process Case Introduction -- Chapter 3 Step 1: Define the Event -- Purpose of Step 1: Define the Event -- Substeps in Step 1: Define the Event -- 1a: Trigger the RCA Process -- 1b: Mandate and Organize the RCA Team -- 1c: Plan the RCA Project -- Gantt Chart -- 1d: Describe the Event in Detail -- Eliminate Bias -- Interview -- Survey -- Checklist for Step 1: Define the Event -- RFO Case Step 1: Define the Event -- Project Planning -- Defining the Event -- Chapter 4 Step 2: Find Causes -- Purpose of Step 2: Find Causes -- Substeps in Step 2: Find Causes -- 2a: Process Mapping -- Flowchart -- Flowchart Example -- 2b: High-Level Mapping -- Contextual and Environmental Factors -- 2c: Brainstorming of Possible Causes -- Fishbone Chart -- Example Fishbone Chart -- Checklist for Step 2: Find Causes -- RFO Case Step 2: Find Causes -- High-Level Mapping -- Identifying Possible Causes -- Chapter 5 Step 3: Find the Root Cause -- Purpose of Step 3: Find the Root Cause -- Substeps in Step 3: Find the Root Cause -- 3a: Categorizing Possible Causes -- Possible Cause Category Examples -- 3b: Constructing a Cause-and-Event Tree -- Example Cause-and-Event Tree.
3c: Analyze Possible Causes to Find the Root Cause -- Five Whys -- Example Five Whys -- Fault Tree -- Example Fault Tree -- Problem Concentration Diagram -- Example Problem Concentration Diagram -- Span of Control Analysis -- 3d: Collate the Findings -- Example Collate the Findings -- Checklist for Step 3: Find the Root Cause -- RFO Case Step 3: Find the Root Cause -- Cause-and-Event Tree -- Five Whys to Find Root Cause -- Collating the Findings -- Chapter 6 Step 4: Find Solution(s) -- Purpose of Step 4: Find Solution(s) -- Substeps in Step 4: Find Solution(s) -- 4a: Explore the Root Cause -- Exploration of the Root Cause in Practice -- 4b: Identify Solution(s) -- Benchmarking -- Using Benchmarking -- 4c: Specify/Describe the Solution(s) -- Checklist for Step 4: Find Solution(s) -- RFO Case Step 4: Find Solution(s) -- Benchmarking for Solutions -- Describing the Solutions -- Chapter 7 Step 5: Take Action -- Purpose of Step 5: Take Action -- Substeps in Step 5: Take Action -- 5a: Analyze the Implementation Setting -- Force Field Analysis -- Example Force Field Analysis -- 5b: Decide on the Implementation Organization -- 5c: Create an Accepted Implementation Plan -- Implementation Plan/Project Proposal Sample Structure -- 5d: Communicate and Create Ownership -- 5e: Implement the Solution -- Checklist for Step 5: Take Action -- RFO Case Step 5: Implementation Analysis -- Deciding on the Implementation Approach -- Implementation Plan -- Creating Awareness -- Chapter 8 Step 6: Measure and Assess -- Purpose of Step 6: Measure and Assess -- Substeps in Step 6: Measure and Assess -- 6a: Conduct a Pilot Study -- 6b: Undertake Measurements -- Other Uses of Measurements -- Effective and Efficient Measurements -- 6c: Assess the Effects -- 6d: Put in Place Safeguards Against Event Reoccurrence -- 6e: Report and Close the RCA Project.
Checklist for Step 6: Measure and Assess -- RFO Case Step 6: Measure and Assess -- Modifying the Solution -- Reporting and Closing the Project -- Chapter 9 Advanced Tools -- Advanced and Basic Tools -- Spider Chart -- The Steps in Using a Spider Chart -- Example Spider Chart -- Critical Incident -- Example of Critical Incident -- Check Sheet -- Example Check Sheet -- Bottleneck Analysis -- Steps in Using Bottleneck Analysis -- Example Bottleneck Analysis -- Histogram -- The Steps in Creating a Histogram -- Example Histogram -- Pareto Analysis -- Example Pareto Chart -- Scatter Chart -- Example Scatter Chart -- Performance Matrix -- The Steps in Using a Performance Matrix -- Example Performance Matrix -- Failure Mode and Effects Analysis (FMEA) -- The Steps in FMEA -- Example FMEA Worksheet -- Six Thinking Hats -- The Steps in Using Six Thinking Hats -- Impact Effort Matrix -- Example Impact Effort Matrix -- Summary -- Chapter 10 Hardwiring the Use of RCA -- Prioritizing Responses and Resource Allocation -- Increasing the Timeliness of RCAs -- Increasing the Strength of Solutions -- Calculating the Business Case -- Using Classification Taxonomies -- Conducting Meta-Analysis of RCAs -- Publishing Results and Creating Best Practice Toolkits -- Providing Transparency in Tools and Training -- Chapter 11 The Future of Root Cause Analysis in Healthcare -- What Is Next? -- Advanced Research: Understanding of the Nature of Human Error and High Reliability Organizations -- Creating a Culture of Safety -- Instituting Policy and Process Specifics -- Increase in Transparency and Incentives -- Increased Standardization -- Collection of Best Practice Data -- Increase in Resources and Training -- Move to Critique and Increase Accountability -- Resources -- A. Templates -- RCA Reporting Framework -- RCA Team Mandate -- RCA Team Composition Template.
Gantt Chart Template -- Fishbone Chart Template -- Five Whys Template -- Force Field Analysis Template -- Spider Chart Template -- Check Sheet Template -- Pareto Chart Template -- Scatter Chart Template -- Performance Matrix Template -- FMEA Worksheet Template -- Impact Effort Matrix Template -- Histogram Template -- B. Guidelines for Evaluating RCAs -- C. Adverse Events -- D. Suggested Further Reading -- E. Institutions and Organizations -- F. RCA Presentation -- G. Resources CD -- Index.
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Intro -- Title page -- CIP data page -- Table of Contents -- CD-ROM Contents -- List of Acronyms -- Preface -- Chapter 1 Root Cause Analysis in Healthcare -- All Organizations Have Problems-Why Is RCA So Important in Healthcare? -- Brief History of RCA in Healthcare -- Definition of a Problem -- Different Levels of Causes -- The Nature of Variation -- Root Cause Analysis -- Related Tool, Processes, and Systems -- System-Level Impediments to Effective RCAs -- Person-Level Impediments to Effective RCAs -- Practice-Level Impediments to Effective RCAs -- Chapter 2 The Root Cause Analysis Process -- The Root Cause Analysis Process -- Explanation of the Table -- Examples -- Full Process Case Introduction -- Chapter 3 Step 1: Define the Event -- Purpose of Step 1: Define the Event -- Substeps in Step 1: Define the Event -- 1a: Trigger the RCA Process -- 1b: Mandate and Organize the RCA Team -- 1c: Plan the RCA Project -- Gantt Chart -- 1d: Describe the Event in Detail -- Eliminate Bias -- Interview -- Survey -- Checklist for Step 1: Define the Event -- RFO Case Step 1: Define the Event -- Project Planning -- Defining the Event -- Chapter 4 Step 2: Find Causes -- Purpose of Step 2: Find Causes -- Substeps in Step 2: Find Causes -- 2a: Process Mapping -- Flowchart -- Flowchart Example -- 2b: High-Level Mapping -- Contextual and Environmental Factors -- 2c: Brainstorming of Possible Causes -- Fishbone Chart -- Example Fishbone Chart -- Checklist for Step 2: Find Causes -- RFO Case Step 2: Find Causes -- High-Level Mapping -- Identifying Possible Causes -- Chapter 5 Step 3: Find the Root Cause -- Purpose of Step 3: Find the Root Cause -- Substeps in Step 3: Find the Root Cause -- 3a: Categorizing Possible Causes -- Possible Cause Category Examples -- 3b: Constructing a Cause-and-Event Tree -- Example Cause-and-Event Tree.

3c: Analyze Possible Causes to Find the Root Cause -- Five Whys -- Example Five Whys -- Fault Tree -- Example Fault Tree -- Problem Concentration Diagram -- Example Problem Concentration Diagram -- Span of Control Analysis -- 3d: Collate the Findings -- Example Collate the Findings -- Checklist for Step 3: Find the Root Cause -- RFO Case Step 3: Find the Root Cause -- Cause-and-Event Tree -- Five Whys to Find Root Cause -- Collating the Findings -- Chapter 6 Step 4: Find Solution(s) -- Purpose of Step 4: Find Solution(s) -- Substeps in Step 4: Find Solution(s) -- 4a: Explore the Root Cause -- Exploration of the Root Cause in Practice -- 4b: Identify Solution(s) -- Benchmarking -- Using Benchmarking -- 4c: Specify/Describe the Solution(s) -- Checklist for Step 4: Find Solution(s) -- RFO Case Step 4: Find Solution(s) -- Benchmarking for Solutions -- Describing the Solutions -- Chapter 7 Step 5: Take Action -- Purpose of Step 5: Take Action -- Substeps in Step 5: Take Action -- 5a: Analyze the Implementation Setting -- Force Field Analysis -- Example Force Field Analysis -- 5b: Decide on the Implementation Organization -- 5c: Create an Accepted Implementation Plan -- Implementation Plan/Project Proposal Sample Structure -- 5d: Communicate and Create Ownership -- 5e: Implement the Solution -- Checklist for Step 5: Take Action -- RFO Case Step 5: Implementation Analysis -- Deciding on the Implementation Approach -- Implementation Plan -- Creating Awareness -- Chapter 8 Step 6: Measure and Assess -- Purpose of Step 6: Measure and Assess -- Substeps in Step 6: Measure and Assess -- 6a: Conduct a Pilot Study -- 6b: Undertake Measurements -- Other Uses of Measurements -- Effective and Efficient Measurements -- 6c: Assess the Effects -- 6d: Put in Place Safeguards Against Event Reoccurrence -- 6e: Report and Close the RCA Project.

Checklist for Step 6: Measure and Assess -- RFO Case Step 6: Measure and Assess -- Modifying the Solution -- Reporting and Closing the Project -- Chapter 9 Advanced Tools -- Advanced and Basic Tools -- Spider Chart -- The Steps in Using a Spider Chart -- Example Spider Chart -- Critical Incident -- Example of Critical Incident -- Check Sheet -- Example Check Sheet -- Bottleneck Analysis -- Steps in Using Bottleneck Analysis -- Example Bottleneck Analysis -- Histogram -- The Steps in Creating a Histogram -- Example Histogram -- Pareto Analysis -- Example Pareto Chart -- Scatter Chart -- Example Scatter Chart -- Performance Matrix -- The Steps in Using a Performance Matrix -- Example Performance Matrix -- Failure Mode and Effects Analysis (FMEA) -- The Steps in FMEA -- Example FMEA Worksheet -- Six Thinking Hats -- The Steps in Using Six Thinking Hats -- Impact Effort Matrix -- Example Impact Effort Matrix -- Summary -- Chapter 10 Hardwiring the Use of RCA -- Prioritizing Responses and Resource Allocation -- Increasing the Timeliness of RCAs -- Increasing the Strength of Solutions -- Calculating the Business Case -- Using Classification Taxonomies -- Conducting Meta-Analysis of RCAs -- Publishing Results and Creating Best Practice Toolkits -- Providing Transparency in Tools and Training -- Chapter 11 The Future of Root Cause Analysis in Healthcare -- What Is Next? -- Advanced Research: Understanding of the Nature of Human Error and High Reliability Organizations -- Creating a Culture of Safety -- Instituting Policy and Process Specifics -- Increase in Transparency and Incentives -- Increased Standardization -- Collection of Best Practice Data -- Increase in Resources and Training -- Move to Critique and Increase Accountability -- Resources -- A. Templates -- RCA Reporting Framework -- RCA Team Mandate -- RCA Team Composition Template.

Gantt Chart Template -- Fishbone Chart Template -- Five Whys Template -- Force Field Analysis Template -- Spider Chart Template -- Check Sheet Template -- Pareto Chart Template -- Scatter Chart Template -- Performance Matrix Template -- FMEA Worksheet Template -- Impact Effort Matrix Template -- Histogram Template -- B. Guidelines for Evaluating RCAs -- C. Adverse Events -- D. Suggested Further Reading -- E. Institutions and Organizations -- F. RCA Presentation -- G. Resources CD -- Index.

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Electronic reproduction. Ann Arbor, Michigan : ProQuest Ebook Central, 2018. Available via World Wide Web. Access may be limited to ProQuest Ebook Central affiliated libraries.

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