decision to do an rca va national center for patient safety rev.02.26.2015 1 the rca process an...
TRANSCRIPT
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 1
The RCA ProcessAn Overview
The RCA Process an Overview
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 2
Flow Chart Process Guide
RCA Team Process
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 3
Decision to do an RCA
RCA Team Process 3
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 4
Immediate Actions
As Required
RCA Team Process 4
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 5
Charter/Appoint Team
RCA Team Process 5
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 6
Decision to do an RCA
Just in Time Training for
Team
RCA Team Process 6
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 7
Decision to do an RCA
Establish Sequence of Events
(First Draft)
RCA Team Process 7
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 8
Decision to do an RCA
IdentifyInformation Gaps
RCA Team Process 8
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 9
Specify Information Required/Who is
Responsible to Get It/ Timeline for Acquiring
RCA Team Process 9
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 10
Use Triage Questions and
RC/Contributing Factor Interview Tools to Frame
Questions
RCA Team Process 10
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 11
Conduct Fact Finding Interviews,
Chart Reviews, and Literature Reviews
RCA Team Process 11
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 12
Synthesize Information
Acquired and Review Using
‘Triage Questions’ and Other Resources
RCA Team Process 12
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 13
Synthesize
Frame Questions
Fact Finding
Information Needed
As Needed
RCA Team Process 13
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 14
Final Version of Sequence
of Events
RCA Team Process 14
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 15
Identify Root Cause/ Contributing Factors
RCA Team Process 15
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 16
Decision to do an RCA
Identify Corrective Actions That Were Instituted
Due to a Similar Event in the Past
RCA Team Process 16
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 17
Develop Action Plan (First Draft)
RCA Team process 17
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 18
Provide Feedback
to Reporter
RCA team Process 18
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 19
Identify What was Learned and Who Needs
to Know
RCA team process 19
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 20
Create Action Planfor Director Concur/
Non-Concur
RCA Team Process 20
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 21
Iterate and Record as Necessary
RCA team process 21
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 22
Determine Approximate Cost
of RCA
RCA team Process 22
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 23
Final RCA and Action Plan
Sign-Off
RCA Team Process 23
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 24
RCA Advisor Conducts Follow-Up
RCA Team Process 24
Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 25
Thank You!
RCA Team Process Thank You