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Strategies Audit Questions |
Tools and Resources
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Effective Process Improvement (EPI) Work Plan |
See work plan here: [DOC]
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General resources |
Case Study Commonwealth Fund: OSF HealthCare: Promoting Patient Safety Through Education and Staff Engagement
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 |
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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
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 |
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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 |
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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 |
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4) Develop solutions/action plans and monitor progress. |
Tool Macomb County Community Mental Health RCA Action plan
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/ |
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5) Share what is learned 6) Spread solutions/action plans |
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