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Root Cause Analysis and Sentinel Event Policy Implementation: Lessons Learned First Considerations Assessment of your organization's "reality" Ask the hard questions Discover feasibility "up-front" Write or revise your plan of action Add or revise policies and procedures (include flow charts) Responsibility and accountability - who does what? Training Methods for monitoring & feedback Implement, monitor and make necessary adjustments Assess: Top Leadership Acceptance of the Sentinel Event Policy Will the CEO support a policy for root cause analysis in response to a sentinel event? Will the Medical Staff leadership support these policies and procedures? What is your organization's policy for reporting sentinel events and root cause analysis to the Joint Commission? Assess: Policies and Procedures Patient or customer complaints Occurrence or incident reporting Medication error reporting Claims and incident investigations Current analysis processes Adverse event or sentinel event policy Performance or continuous improvement Clinical or practice pathway variances Assess: Organizational "Climate" Do you have a culture which supports continuous improvement? Are your health care providers competent in using the tools of process improvement? Does your leadership emphasize "patient satisfaction"? Does your organization place importance on "patient safety"? Do employees and medical staff report incidents/events in a timely manner? Do staff "fear" punitive measures against them for reporting adverse events? Does information flow freely throughout the organization? Assess: Organizational Training Requirements Are resources for training available? Identify what to teach Who will provide root cause analysis training for the staff? Do you in-house expertise in this area? Will you have to "out source"? Which staff members will require specialized training? How best can training be delivered? Assess: Information Management Resources Do you have internal or Internet access? Do you have email capability? Do you have an organization-wide Intranet? Do you have the capability to electronically pass documents between employees? Can this new technology be useful for instruction and "internal marketing". Create a Risk Management Committee Multi-disciplanary team Meet regularly to discuss risk exposure issues Holds protected, secure data repository Active medical staff membership Review of events and assignment of root cause analysis (include "near misses") Review and approval of each completed root cause analysis Points to Consider: Lessons Learned Get Senior Leadership Support Up Front Strive toward a culture of patient safety Revised written plan, policies and procedures RM Program Training All departments and work centers Involved medical staff in training Continuous Improvement Collaborative Specialized performance improvement training for department representatives Root cause analysis training is key Use Intranet/LAN for online training and support Close collaboration with Performance Improvement Office Medical Staff Leadership Nursing Leadership Legal Counsel More Lessons Learned Remember to keep your sense of humor Cultivate "physician champions" Keep medical staff involved in all steps of the process Keep the leadership informed Teach, teach and teach some more... Concentrate on support and assistance for the root cause analysis process Ensure a literature search accompanies each root cause analysis if at all appropriate Constantly pursue the "credible and thorough" root cause analysis Ensure that your organization has a process to monitor and measure recommendations and improvements Yet More Lessens Learned Spotlight your root cause analysis superstars Create a award/reward/incentive system for participation Be patient - stay for the "long run" Ensure each root cause analysis is conducted by an "expert" team Ensure feedback to participants. Root Cause Analyst TM Software | FAQs on the Issues | Root Cause Analysis Training Cost-Effective Root Cause Analysis | Root Cause Analysis Software - Article Resource Links | Guestbook | About MRMA | Email MRMA  Root Cause AnalystTM is developed in partnership with Accurate Assessments. Call 1-800-324-7966 to find out how to purchase Root Cause AnalystTM or visit the Accurate Assessments Web site at www.accurateassessments.com Copyright© 1998,1999,2000 MRMA, LLC. All rights reserved. All other trademarks are the sole property of their respective owners. Page last modified 21 March 2000.