Strategies for Adverse Event Analysis

Healthcare Performance Improvement is the leader in using evidence-based root cause analysis to prevent event recurrence. As a group, HPI consultants have led hundreds of root cause analyses for system breakdowns, management effectiveness, equipment malfunctions, and human error. Evidence-based root cause analysis uses a comprehensive understanding of cause-and-effect relationships in complex systems as a diagnostic tool. In absence of evidence-based root cause analysis, healthcare gravitates to only three risk reduction strategies: change the policy, educate the staff, and counsel the individuals to try harder. These strategies describe 95% of the actions specified in healthcare. The HPI methodology addresses the complex system and expands awareness of other causal factors and risk reduction strategies, thereby increasing the probability of preventing recurrence.

This diagnostic approach to understanding cause-and-effect relationships forms the foundation for the HPI method of building and sustaining human performance excellence that results in improvements in safety, quality, and satisfaction in the healthcare industry. Our consultant team brings experience and expertise in human performance improvement in high-risk industries with experience and expertise in healthcare application and implementation.

Root Cause Analysis Education & Program Implementation
Training courses are provided to educate individuals as root cause analysts at the beginning and advanced levels. The course is technology independent in that the basic root cause process and the root cause analysis techniques can be used with any diagnostic system. Class participants receive a bound copy of the course notes, a memory aid card for problem solving, and work sheets and templates describing and illustrating various tools for analysis of events

Group Training for Root Cause Analysts
Interactive workshops provide practical training for individuals identified by the organization as root cause investigators in the coordination and facilitation of RCA methods. The participants receive training on structured approaches to RCA that have been successfully used in health care and other high risk industries and on effective error reduction approaches linked to the various types of root causes. Upon completion of the training, these individuals can then function as internal resources to the organization for future RCAs.

Mentoring of Root Cause Analysts
In order to further develop analyst skills, mentoring sessions can be scheduled to provide reinforcement of the skills taught during the training sessions and to ensure the skills are appropriately implemented. It is accomplished by participation of the HPI consultant with actual RCA project teams and interim work with the RCA investigators.

Root Cause and Common Cause Analysis Application
Many healthcare organizations have extensive experience in performing root cause analyses, however periodically additional expertise is required for various serious or recurring event analyses that use more in depth techniques of analysis and particularly in understanding human factors and system and process failure modes of a specific event or common themes among past events. Working with local root cause resources, HPI can guide and facilitate root cause analysis of a specific event, or conduct a common cause analysis on a series of recurring events of similar nature. The process will result in a plan of action to prevent recurrence.

Activities include HPI consultant work with the local RCA team to construct of a sequence of events of the current event and review remedial actions and extent of condition, design of follow-up investigations, completion of the analysis of the event causal factors, identification of the root cause(s), and development of an action plan to prevent recurrence.