Medicine and Health Sciences Commons^™

Root Cause Analysis To Improve Incident Reporting In An Ambulatory Care Setting, Lisa Ann Duncan

Doctor of Nursing Practice (DNP) Projects

Problem: The subject organization (SO) is a Federally Qualified Health Center (FQHC) with an internally developed incident reporting system. The SO wanted to improve patient and employee safety using data from incident reports, but the incident reporting system did not give enough information to recognize patterns and develop countermeasures.

Context: Supervisors welcomed the opportunity to learn more about incident report follow-up and conducting root cause analysis (RCA). Members of the Safety Committee were eager for data to use to develop countermeasures to improve patient and employee safety. Decreases in employee injuries can save the SO from increases in the …

Coordination Of Inpatient And Outpatient Care For Neurology Patients Undergoing Epilepsy Monitoring, Sara Schrock, Michelle Beane, Kathryn Cope, Mark Parker, Suneela Nayak, Ruth Hanselman, Stephen Tyzik, Amy Sparks, Brendan Lilley

Operations Transformation

ORGANIZING A SYSTEM TO CONSOLIDATE EPILEPSY REFERRALS TO AN OUTPATIENT NEUROLOGY PRACTICE

An outpatient neurology practice was experiencing delayed or lost referrals for epilepsy monitoring. This delay was leading many patients to suffer unnecessary and unmanaged seizures and, in some cases, frequent trips to the emergency department.

As a result, a team consisting of the neurology practice and neuro-navigators used baseline metrics to demonstrate the current state of the problem and conducted a root cause analysis that outlined several causes. A number of countermeasures were initiated with the goal of decreasing referral misses.

Post the initiation of two KPIs, a …

Sustaining Daily Management With Gemba Walks: A Scheduling Model, Suneela Nayak, Ruth Hanselman, Stephen Tyzik, Amy Sparks

Operations Transformation

SUSTAINING DAILY MANAGEMENT WITH GEMBA WALKS: A SCHEDULING MODEL

At an academic tertiary care medical center, there are 110 Operational Excellence teams across 4 campuses. Every weekday, 10 GEMBA walks occur with the 11^th on Wednesdays. The expanding program has made daily leadership visits to all KPIs challenging. As a result, consideration of reduced gemba walks to departments who have met specific maturity/performance criteria.

The scope of the eight-week pilot consisted of 13 pre-identified teams that have weekly workflows. The teams must have met a baseline level of performance. Performance was scored for 9 variables measuring engagement, PDSA, use …

Reducing O Negative Blood Product Usage In A Tertiary Care Academic Medical Center, Wendy Weiler, Tracy Cook, Mmc Blood Bank, Mark Parker, Stephen Tyzik, Suneela Nayak, Ruth Hanselman, Amy Sparks

Operations Transformation

MANAGEMENT OF O NEGATIVE BLOOD USE

O registered blood cells are the universal donor but it comprises only 7% of the blood supply. As a result, inappropriate use can result in shortages.

At an academic tertiary care medical center, a performance improvement goal was established that O negative blood cells would make up less than 12% of all blood type transfused by the end of their fiscal year.

A root cause analysis established reasons for the use of O negative blood cells. A number of countermeasures were initiated using the plan, do, study, act (PDSA) problem solving model. Using newly …

Strategies To Improve Post-Procedural Safe Patient Handoffs, Marguerite Peggy Anderson, Tara Herman, Janice Nichols, Robyn Dixon, Elizabeth Van Der Linden, Bonnie Boivin, Stephen Tyzik

Operations Transformation

STRATEGIES TO IMPROVE SAFE PATIENT HANDOFFS AND POST PROCEDURAL FLOW

During patient transfers from one care unit to another, it is imperative for patient safety and satisfaction that timely and complete communication between staff occurs. In an academic tertiary care medical center, a team consisting of representatives from 6 patient care units used improvement methods of operational excellence to improve patient centered movement.

The goal of this project was to improve the percentages of two questions related to information sharing on the FY2018 AHRQ Culture of Patient Safety Survey. Using baseline metrics to reflect the current state of patient wait …

Increasing Bedside Medication Safety In An Intensive Care Setting, Natasha Stankiewicz, Jonathan Archibald, Scu 2, Mark Parker, Stephen Tyzik, Suneela Nayak, Ruth Hanselman, Amy Sparks

Operations Transformation

A PERFORMANCE IMPROVEMENT PROJECT FOR INCREASED BEDSIDE MEDICATION SAFETY

The convenience of having certain medications directly available at bedside has long been a priority for a medical intensive care nursing team in an academic tertiary medical center.

However, it was apparent to new staff and leadership that there was a lack of awareness and interest in securing medications within the department. This posed a risk to patients, families, visitors and colleagues.

Baseline metrics on patient safety were collected and a root cause analysis was conducted. Countermeasures included increased education of medication safety as well as a instituting a KPI which …

Strategies To Improve Resource Availability For New Graduate Nurses In A Critical Care Setting, Natasha Stankiewicz, Jonathan Archibald, Shawn Taylor, Deborah Jackson, Bonnie Boivin, Mark Parker, Suneela Nayak, Stephen Tyzik, Ruth Hanselman, Amy Sparks

Operations Transformation

STRATEGIES TO IMPROVE RESOURCE AVAILABILITY FOR NEW GRADUATE NURSES

Due to changes in the employment arena, health care organizations are hiring new graduate RNs into acute care. At an academic tertiary medical center, new hires typically are assigned into a night shift, which traditionally has less resource availability.

The results of a recent AHRQ hospital survey on patient culture safety demonstrated that new graduates were feeling unsupported and that patient safety could be potentially compromised. A team of caregivers developed several goals to provide increased support, encouragement and education to night shift new hires. Improvement in overall patient care and …

Interprofessional Engagement In Lean Improvement In An Academic Healthcare Organization, Mark Parker, Suneela Nayak, Stephen Tyzik, Ruth Hanselman, Amy Sparks, Linda Simonsen

Operations Transformation

STRATEGIES TO INCREASE ENGAGEMENT OF PROVIDERS IN LEAN APPLICATIONS IN AN ACUTE TERTIARY CARE HOSPITAL

Engaging care providers in interprofessional LEAN applications in an academic tertiary hospital results in safe, reliable and effective patient care. An initial success measure was established to increase LEAN application engagement to 36%, with the goal of reaching 50% within 3 years of their operational excellence go-live.

A root cause analysis established several causes for low involvement. Using operational excellence strategies, a number of countermeasures were created, rolled out and completed. As a result, follow up metrics demonstrated a marked increase in the number of …

Strategies To Increase Early Discharges To Decrease Hospital Length Of Stay And Avoidable Patient Days For Neuro-Spine Patients, Corey Fravert, Joy Moody, Mark Parker, Suneela Nayak, Stephen Tyzik, Ruth Hanselman, Amy Sparks

Operations Transformation

STRATEGIES TO INCREASE MORNING DISCHARGES IN AN ACADEMIC TERTIARY HOSPITAL

Delays in patient discharge result in numerous negative impacts on the health care system. Amongst those are a reduced patient flow and satisfaction, long wait times, and physician/ staff frustration.

An inpatient neurotrauma unit initiated a performance improvement project that utilized a multidisciplinary approach to identify barriers to discharge and coordinate a discharge plan focused on neurospine patients.

A root cause analysis was conducted to collect reasons that these patients were not discharged by 11:00am. As a result of the findings, 4 performance improvement plans were created. Subsequent data collection …

Consistently Using A Transportation Department For Patient Discharge To Sustain Nursing Staffing Levels, Victoria Boutin, Joseph East, Stephen Tyzik, Joy Moody, Mark Parker, Suneela Nayak, Ruth Hanselman, Amy Sparks

Operations Transformation

IMPROVING PATIENT FLOW BY UTILIZING A HOSPITAL TRANSPORTATION DEPARTMENT FOR DISCHARGES

Using a transportation department for transporting patients for discharge is the industry standard. At a large urban hospital, inconsistent use of this department has resulted in frontline caregivers (RNs) having to pick up this function, resulting in potentially unsafe staffing levels on the floor.

The goal of this quality improvement project was to improve the percent of discharges with the transport department from ≤10% to 70% by the end is fiscal year 2018 in an academic tertiary medical center.

Baseline metrics demonstrated the current state and a root cause …

Effect Of Root Cause Analysis On Pre-Licensure, Senior-Level Nursing Students’ Safe Medication Administration Practices, Kristi Miller

Electronic Theses and Dissertations

Aim: The aim of this study was to examine if student nurse participation in root cause analysis has the potential to reduce harm to patients from medication errors by increasing student nurse sensitivity to signal and responder bias.

Background: Schools of nursing have traditionally relied on strategies that focus on individual characteristics and responsibility to prevent harm to patients. The modern patient safety movement encourages utilization of systems theory strategies like Root Cause Analysis (RCA). The Patient Risk Detection Theory (Despins, Scott-Cawiezell, & Rouder, 2010) supports the use of nurse training to reduce harm to patients.

Method. Descriptive and …

Converting Serious Safety Events Into Educational Opportunities, Michael Joseph Vitto

Health Sciences Education Symposium

Over the past year, the Associate Director of the Simulation Center worked with the EM Quality and Safety Director to identify serious safety events (SSE) and critical incidents. As part of the case review, an informal root cause analysis (RCA) was conducted and root causes related to safety risks or breakdowns were identified. These system vulnerabilities were woven into simulation cases for hospital code team training. The cases focused on skills and attitudes that would help prevent, capture, or mitigate similar vulnerabilities while providing clinical care. The objective of this educational innovation was to intentionally translate lessons learned from SSE …