Improving RCA performance: the Cornerstone Award and the power of positive reinforcement.
ABSTRACT The Veterans Health Administration has had a comprehensive patient safety program since 1999 that includes conducting root cause analysis (RCA) of adverse medical events. Improving the quality and timeliness of the RCAs at the local level has been a continual challenge.
We initiated a non-monetary program called the Cornerstone Award into our patient safety reporting system to recognise facilities conducting high-quality and timely RCAs containing deterministic corrective actions that are implemented and evaluated for effectiveness.
Since the Cornerstone Program began in 2008, the per cent of RCAs completed in a time-critical manner (≤45 days) has increased from an average of 52% pre-Cornerstone to an average of 94% post-Cornerstone. The per cent of action plans with stronger deterministic actions and outcomes has increased from an average of 34% pre-Cornerstone to an average of 70% post-Cornerstone.
Implementing a non-monetary recognition award that was tied to specific improvement goals greatly improved the timeliness and quality of the RCA reports in the Veterans Health Administration System.
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ABSTRACT: In recent years, the healthcare sector has adopted the use of operational risk assessment tools to help understand the systems issues that lead to patient safety incidents. But although these problem-focused tools have improved the ability of healthcare organizations to identify hazards, they have not translated into measurable improvements in patient safety. One possible reason for this is a lack of support for the solution-focused process of risk control. This article describes a content analysis of the risk management strategies, policies, and procedures at all acute (i.e., hospital), mental health, and ambulance trusts (health service organizations) in the East of England area of the British National Health Service. The primary goal was to determine what organizational-level guidance exists to support risk control practice. A secondary goal was to examine the risk evaluation guidance provided by these trusts. With regard to risk control, we found an almost complete lack of useful guidance to promote good practice. With regard to risk evaluation, the trusts relied exclusively on risk matrices. A number of weaknesses were found in the use of this tool, especially related to the guidance for scoring an event's likelihood. We make a number of recommendations to address these concerns. The guidance assessed provides insufficient support for risk control and risk evaluation. This may present a significant barrier to the success of risk management approaches in improving patient safety.Risk Analysis 12/2013; · 2.28 Impact Factor
- BMJ quality & safety 01/2012; 21(4):267-70. · 3.28 Impact Factor
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ABSTRACT: Since 1999, hospitals have made substantial commitments to health care quality and patient safety through individual initiatives of executive leadership involvement in quality, investments in safety culture, education and training for medical students and residents in quality and safety, the creation of patient safety committees, and implementation of patient safety reporting systems. At the Weinberg Surgical Suite at The Johns Hopkins Hospital (Baltimore), a 16-operating-room inpatient/outpatient cancer center, a patient safety reporting process was developed to maximize the usefulness of the reports and the long-term sustainability of quality improvements arising from them. A six-phase framework was created incorporating UHC's Patient Safety Net (PSN): Identify, report, analyze, mitigate, reward, and follow up. Unique features of this process included a multidisciplinary team to review reports, mitigate hazards, educate and empower providers, recognize the identifying/reporting individuals or groups with "Good Catch" awards, and follow up to determine if quality improvements were sustained over time. Good Catch awards have been given in recognition of 29 patient safety hazards identified since 2008; in each of these cases, an initiative was developed to mitigate the original hazard. Twenty-five (86%) of the associated quality improvements have been sustained. Two Good Catch award-winning projects--vials of heparin with an unusually high concentration of the drug that posed a potential overdose hazard and a rapid infusion device that resisted practitioner control--are described in detail. A multidisciplinary team's analysis and mitigation of hazards identified in a patient safety reporting process entailed positive recognition with a Good Catch award, education of practitioners, and long-term follow-up.Joint Commission journal on quality and patient safety / Joint Commission Resources 08/2012; 38(8):339-47.