Strategies

Audit Questions

Tools and Resources

 

Effective Process Improvement (EPI) Work Plan

See work plan here: [DOC]

 

General resources

Case Study

Commonwealth Fund: OSF HealthCare: Promoting Patient Safety Through Education and Staff Engagement

http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2011/Feb/1475_McCarthy_OSF_case_study_FINAL_v3.pdf

 

Case Study

http://www.ahrq.gov/about/casestudies/ptsafety/

 

Tool

The Nebraska Center for Rural Health Research includes tools, checklists, presentations, case studies, etc. for Reporting Culture, Just Culture, Flexible Culture and Learning Culture.  http://www.unmc.edu/rural/patient-safety/Toolbox/Learning%20Culture/Learning.htm

1) Develop a robust system of data-gathering that can improve patient safety and quality

Tool

The Nebraska Center for Rural Health Research

http://www.unmc.edu/rural/patient-safety/Toolbox/Learning%20Culture/Learning.htm

 

Tool

Dana Farber Patient Safety Electronic Reporting Form

https://www.dana-farber.org/apps/patient-safety-form.aspx

 

Tool

Dana Farber Patient Safety Rounds Toolkit

http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Care-Quality-and-Safety/Patient-Safety-Resources.aspx#Patient_Safety_Rounding_Toolkit

 

Tool

IHI: Trigger Tools

http://www.ihi.org/explore/TriggerTools/Pages/default.aspx

 

Tool

Integrated Incident Reporting Form http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2213474/figure/fig1/

 

Report

Integrating reporting into EMR http://psnet.ahrq.gov/resource.aspx?resourceID=5022

 

Website

Minnesota Department of Health Adverse Health Care Events Reporting System

http://www.health.state.mn.us/patientsafety/

2) Use evidence-based prospective analysis methods to identify potential failures in care.

Article

Joint Commission Journal on Quality and Patient Safety article: "A Practical Guide to Failure Mode and Effects Analysis”

http://www.calidadasistencial.es/images/gestion/biblioteca/268.pdf

 

Article

Journal of System Safety: "Reducing Patient Healthcare Safety Risks Through Fault Tree Analysis": http://www.patientsystemsafety.com/upload/JSSFTA.pdf

 

Tool

IHI: FMEA Toolkit

http://www.ihi.org/knowledge/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx

 

Tool

Joint Commission FMEA tools

http://www.jointcommission.org/assets/1/18/Fmeca.pdf

 

Videoconference Course

The Basics of Healthcare Failure Mode and Effect Analysis – Videoconference Course presented by: VA National Center for Patient Safety http://www.patientsafety.gov/SafetyTopics/HFMEA/FMEA2.pdf

3) Use evidence-based retrospective methods of analysis to identify root causes of problems or events.

Tool

The Nebraska Center for Rural Health Research

http://www.unmc.edu/rural/patient-safety/Toolbox/Learning%20Culture/Learning.htm

 

Tool

US Dept. of Veterans Affairs RCA tools  http://www.patientsafety.gov/CogAids/RCA/index.html#page=page-1

 

Training

Minnesota Department of Health RCA training

http://www.health.state.mn.us/patientsafety/training/index.html

4) Develop solutions/action plans and monitor progress.

Tool

Macomb County Community Mental Health RCA Action plan

http://www.mccmh.net/Portals/0/MCO%20Policies/8%20QI/Sentinel%20Events,%20RCA,%20Mort.%20Rev/Ex.%20E%208-003.pdf

 

Tool

Joint Commission: Conducting a Root Cause Analysis and Action Plan

http://www.jointcommission.org/Framework_for_Conducting_a_Root_Cause_Analysis_and_Action_Plan/

5) Share what is learned

6) Spread solutions/action plans