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Root Cause Analysis |
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Root Cause Analysis for Healthcare
RCA Solutions offers on-site consulting services, web-based classes and
quarterly off site workshops. Our educators teach healthcare professionals how
to conduct an efficient Root Cause Analysis . Our three meeting approach is
constructed to meet standards set forth by The Joint Commission (JCAHO) and
addresses utilization of the forms created by JCAHO. The following questions are
routinely posed by our clients and are addressed within our educational
materials. |
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- When do I need to conduct a Root Cause Analysis?
- What do policies and procedures for conducting a Root Cause Analysis need to include?
- Which approach would be best for our environment?
- What do I need to know about peer review, apology laws and/or discovery laws?
- Should legal counsel be involved in the Root Cause Analysis?
- Who should be on the inter-disciplinary team?
- What does JCAHO require for a Root Cause Analysis?
- Where can I obtain a sample of a completed Root Cause Analysis?
- What constitutes a robust Literature Review?
- How can I calculate return on investment from a quality and monetary perspective?
- What is the difference between a Sequence of Events and an Optimal Sequence of Events?
- Why is there always multiple contributory factors in an analysis?
- How many root causes should be uncovered in one analysis?
- How can you use a simplified FMEA to prioritize action items?
- How do I know when it is time to utilize FMEA in conjunction with RCA?
- How does incident reporting relate to RCA and FMEA?
- What kind of software should I use?
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The term "cause" implies, obviously, causation. In health care there are many
situations wherein it is a unique combination of circumstances which leads to an
adverse event, and no single or even pair of "causes" are necessary and/or
sufficient to bring about the event. The circumstances merely increase the
likelihood of the adverse outcome, and are thus contributory in nature, rather
than causative. |
Create an Action Plan
Rank proposed solutions
Priortize
Define barriers to implementation
Uncover root causes
Offer long term solutions both short and long term strategies
Be positive and objective
Schedule action items and follow up
Measurable Results
Study Data
Measure results
Leverage subject matter experts
Utilize experts in information management and quality improvement & communicate
results
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A corrective action may consist of recommending that the responsible party or
office within the organization appoint and charter a process action team to
examine a specific root cause in more detail, in order to develop a strategy for
improvement. It is not necessarily the obligation of the root cause analysis
team to find all the solutions — only to find all the contributors, report them,
and recommend the means by which they can be addressed for improvement. |
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