Root Cause Analysis

Root Cause Analysis (RCA) is a problem-solving tool that is most frequently used to determine the basic underlying factor(s) responsible for an event (ie, its root cause). This analysis is then used to determine the best method of preventing that event from occurring again.

A multitude of different RCA methods are available, but most of them have some basic principles in common. An RCA involves a systematic, data-driven, well-documented investigation into an event. It is a reactive method used to identify the steps in a system or process that are prone to failure, to determine the one or ones that failed and caused the event under investigation, and to determine how to prevent the failure from recurring. The RCA will also determine how many other factors were affected by the event under investigation.

The first step in an RCA is to clearly and factually describe the event or problem. Often the initial description of the problem will involve a timeline description of the proper process, the way the system SHOULD work, and then define the point or points at which the event under investigation differed from the proper course of events. Thus most RCA include a timeline, qualitative and quantitative data depicting the proper process and the failure steps, and thorough documentation of each step. Data is collected wherever necessary in order to be making decisions from data rather than from assumptions of how the system works. Once the root cause or causes of a problem have been clearly determined, an RCA again uses data to identify corrective actions to remedy anything that is wrong due to problem, as well as corrective actions to prevent the same problem from occurring in the future

Let’s pretend that patient test results were reported with the incorrect reference interval. In order to determine why this happened, we start by making a timeline depicting each step in the normal process. In our example, this means reviewing all the procedures in place for setting, maintaining, and changing reference intervals. Then, step by step, it can be determined where the process failed in this specific case, as well as other steps that might be prone to failure. Corrective actions to amend any incorrect patient results and notify caregivers would begin immediately, with thorough documentation. Once the root cause of the process failure is clearly identified and the step or steps that failed have been determined, additional corrective actions would be taken to remedy the necessary steps in the process so that this error cannot recur. Occasionally an RCA will lead to instituting an entirely new process in order to prevent problem recurrence. It’s important to note that everything associated with the RCA is fully documented.

Identifying and implementing solutions is probably the most important part of an RCA, yet it cannot occur effectively if the actual bottom-line cause of the problem has not been correctly identified in the first part of the process. If the root cause has not been correctly identified, the solutions become only a temporary patch on the problem, and the problem it will occur again. RCA generally involve time and work to do properly, and yet can be incredibly useful in preventing a recurrence. In a hospital or laboratory environment where potential patient harm can occur when a mistake it made, the RCA is often an important part of operating a healthcare system.

 

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-Patti Jones PhD, DABCC, FACB, is the Clinical Director of the Chemistry and Metabolic Disease Laboratories at Children’s Medical Center in Dallas, TX and a Professor of Pathology at University of Texas Southwestern Medical Center in Dallas.

Advice for the Incoming PGY-1 Residents

As I am repeating the motions of yesteryear when I was moving from NJ to Chicago to start my residency, except this time in reverse to return to NJ to complete the final two years of my residency, I’m reminded that it’s always good to ask for advice from those who have blazed the trail before me. And so I’d like to start with a hearty CONGRATULATIONS to the incoming pathology PGY-1 residents! This is truly a time of excitement and maybe a little apprehension of the new and unknown for you. So, I thought that I’d devote this week’s blog to pearls of wisdom I’ve picked up along the way. Fellow residents, please pipe in if you also have some advice for our incoming residents.

  1. Enjoy your time before residency (and in some of cases, June orientation a la boot camp style) starts. Take that vacation backpacking through Europe that you always dreamed of…or volunteer overseas if you’re so inclined. Whatever you do, take some “me time” now. I know it’s easy to think that you might need to read up on your pathology but there’s time for that later. Once you start working (residency, fellowship, job), even if you are promised 4 weeks, it might be difficult to schedule that time off due to grossing schedules, your colleagues’ vacation requests, and so on. So decompress from the past 4 years of medical school and enjoy what’s left of your summer.
  2. Hopefully, you already have done this but look for your housing way in advance, especially if you are out-of-state from where you will be a resident. Apartment websites and Craigslist are good but be careful of scams especially if they ask you send in a deposit ahead of time without seeing the place. If something sounds too good to be true, it probably is. I strongly suggest going in-person or having a trusted friend or family member check out places for you if you can’t. A great piece of advice that was given to me was to use a realtor (or more than one) who can line up places and show you around. They are usually a good source of information about where is best to live and what are reasonable prices…and you can ask them to only show you places where the landlord pays the commission. It saves time to have someone organize the appointments according to your specifications (pets, within X distance to the hospital, safety, covered utilities, parking, amenities, etc) so that you only need to show up and view the places you like and decrease the number of apartment hunting trips/calls you make. You can even search for places you like off the realtors’ website just like you’d do on Craigslist, Trulia, or Zillow especially if you want to rent or buy a condo unit. Sometimes you may need a letter of employment stating your salary and a credit report (by federal law, you can get this free q12mo from all 3 credit reporting companies through www.annualcreditreport.com but you will need to pay a small fee, about $10, to get the credit score – you can get the score free via Credit Karma but a lot of realtors will not accept it from this company so be forewarned)
  3. Think about selling any large items you may have (such as furniture) to save on moving costs. If you really must move a lot of large items, look into moving options early because June/July is a busy moving cycle and you don’t want to be left with the less reputable companies that may be cheap but do not do a good job or very high prices or even worse, no options. You can either hire a moving company or use portable containers such as PODS, U-Haul’s U-box, or ABF U-Pack where you pack the container yourself and they drive the container to your new home and often have options to store it until you are ready to access it. Check to see if your program has an Employee Assistance Program (EAP) that can help you with relocation services and/or discounts but either way budget yourself 1-2 grand.
  4. Get all your paperwork done ASAP. You will receive mountains of forms that need to be filled out to obtain your (temporary) medical license and allow you access to the various hospitals you will rotate at. Make it a habit now to not procrastinate because once residency starts, you will find yourself often too busy and too tired. You also do not want any delay in starting your job due to incomplete paperwork. Better to find out now if you are missing an item (eg – vaccination, physicals) and take care of it before you arrive to start.
  5. Get to know your colleagues. Introduce yourself to everyone over email and offer to help out if they need (such as unloading their moving stuff). It’s a great way to break the ice and meet your fellow residents and start off on a friendly foot. You can even suggest some chillaxing activities to do together at the start of residency to explore your new city to get to know each other and your new home. Bonding starts from day one and it is difficult to do once the hustle and bustle of work starts and if you are in a program where you are separated to different hospitals. Also, you’ll find that your senior residents will have a lot of good advice to give and you might even find a new friend or mentor.
  6. Join pathology advocacy organizations like the American Society of Clinical Pathology (ASCP), the College of American Pathologists (CAP), and your state/city pathology societies because they often have resident resources and this is the last time you can get free membership. Once you graduate, then you have to pay membership dues. CAP has a Residents Forum with 2 meetings per year that I found a great place to meet other residents. Both ASCP and CAP have a Resident Council and Residents Forum Executive Committee, respectively. Get involved and run for a position on either of these or on ASCP or CAP committees where you will serve with attendings. Other international organizations such as USCAP or subspecialty organizations may have dues but these are often greatly discounted for trainee members and you get discounted registration if you need to attend their conference (eg – to present a poster) so it still makes sense to join – find out if your program will pay for the dues.

Once you start residency, I won’t lie, it will be stressful. There will be times you wonder what you’ve gotten yourself into and when you may doubt if you can do all that is expected of you. But persevere and this, too, shall pass. Find yourself some good mentors – other residents, attendings, and/or ancillary staff. You may feel that you are behind and that there is so much to learn but I promise if you make sure you have a solid foundation at each step, one day you will be that senior resident who seems to know so much more than you did on day one. But for now, enjoy yourself! The studying can wait–at least until July 1st!

 

Chung

Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

Professional Societies Abroad

In my last post I wrote about how Lab Week was being celebrated around the world. In that post I mentioned two medical laboratory associations that are up and coming in their respective countries and working hard to provide a voice for laboratory professionals. These organizations are the Association Ivoirienne de Biologie Technique (l’AIBT) in Cote d’Ivoire and the Medical Laboratory Scientists Association of Tanzania (MeLSAT). These two organizations are among a growing group in Africa recognizing the importance of professional associations to provide a voice, educational resources, and other tools for medical laboratory professionals.

Over the past few years the Centers for Disease Control has been a leader in helping facilitate the development of the African Society for Laboratory Medicine (ASLM). According to the ASLM website, the organization “is a pan-African professional body working to advocate for the critical role and needs of laboratory medicine and networks throughout Africa.” ASLM provides membership opportunities, continuing education, publishes a journal, and implements the WHO AFRO framework for improving medical laboratories in Africa called SLIPTA (Stepwise Laboratory Quality Improvement Process Towards Accreditation).

While ASLM focuses on providing services and member benefits across the African continent, L’AIBT and MeLSAT serve the local communities in their respective countries. You can find more information about l’AIBT on their facebook page, which features photos and posts on l’AIBT activities in Cote d’Ivoire and their website.  For more information on MeLSAT, you can visit their website, which also has a job postings page for lab professionals looking for opportunities in Tanzania. Both organizations have benefited from mentorship support from ASCP and have begun a dialogue with each other to exchange information and best practices. As they continue to develop and grow they will be important resources for local laboratory professionals and can provide an important network of professionals throughout the continent.

 

Levy

-Marie Levy spent over five years working at American Society for Clinical Pathology in the Global Outreach department.

A Trifecta: It’s About Time!

I am always amazed and interested at how events often occur in 3’s. If you are from Kentucky (or follow the “ponies”) you are likely familiar with the racing 3’s, aka the Triple Crown, of which the Derby is the opening event. There is also the trifecta which is defined as a successful bet for the top three winners in a race: win, place, and show. Well, I believe we have recently (and I might add, finally) achieved a trifecta for Patient Blood Management (PBM).

The trifecta of which I speak is the long-awaited and anticipated national recognition of PBM and thus, transfusion safety.

The first of the three events which initiated my designated trifecta was the American Medical Association and Joint Commission Overuse Summit which took place in 2012. Blood transfusions were recognized and listed within this committee’s top five over-utilized procedures/therapies. A complete discussion of the findings of this summit has been published on the Joint Commission’s website.¹

The second and equally important event was the soon-to-follow Choosing Wisely Campaign, sponsored by the American Board of Internal Medicine (ABIM) Foundation in 2013. Two of the top 5 recommendations pertain to PBM. Restrictive transfusion practices and minimizing overuse of laboratory testing which avoids iatrogenic blood loss anemia were both highlighted.² Several professional societies have embraced the Choosing Wisely Campaign and now have published specific recommendations for their own subspecialties. These include the American Society of Hematologists (ASH), American Association of Blood Banks (AABB), the American Society for Clinical Pathology (ASCP), and the American Society of Anesthesiologists (ASA). The list continues to grow. The American Hospital Association (AHA) has subsequently published a white paper mirroring these recommendations.³

And then the veritable “icing on the cake” has been the recent 2014 release of the AABB Standards for PBM.⁴ These standards place direct focus on the numerous distinct elements of a robust PBM program with levels of activity for all facilities/systems large and small. I imagine many of you have seen the May issue of the AABB News.⁵ This entire publication speaks to the integrated efforts of the ABIM, AHA and other groups that now have joined, in unison, the song of PBM.

Many of us have been beating the PBM drum for several years. Even those of you that are early in your “journey” are embracing it readily in your loco-regional arena. I applaud you! We should be pleased and proud that the drums have finally resonated with leaders of our nationally-recognized societies, accreditation bodies and medical professional groups. This will help to bring PBM and our mission for transfusion safety even more directly into the limelight.

I’m a good old Kentucky girl and I love to score a trifecta. This is a good one and it’s about time!

References:

¹www.jointcommission.org/overuse_summit/

²www.choosingwisely.org

³www.aha.org

⁴www.aabb.org

⁵AABB News, May, 2014; 16: 1-22

 

Burns

-Carolyn D. Burns, MD, is a Board Certified Pathologist who has worked as a medical director for transfusion services and an assistant clinical professor of pathology. She frequently speaks about topics such as transfusion reactions, transfusion in solid organ transplant, and anticoagulant/antiplatelet reversal strategies.

 

Improving Healthcare Delivery: Effective Performance Improvement

How do you conduct effective performance improvement for your clinical laboratory when facing the complex challenges under the Affordable Care Act (ACA) 2010 and regulatory compliances? Producing healthy revenues and manageable costs are crucial components and challenging objectives for any organizations. Healthcare organizations have performed strategic renewals and redesigned their business operations by enlisting performance improvement plans. However, after all that hard work, many organizations still end up with large deficits to their operational budgets and non-compliances on their accreditation agencies’ regulatory requirements that may require drastic measures to rectify (such as employee lay-off or early retirements). Some organizations, even after performance improvement programs or formal business reengineering, will end up closing their doors. According to Harvard Business Review, among Fortune 1000 companies, success rates of business reengineering is lower than 50 percent and can be as low as 20 percent! What can be learned from this? How do you get employees on-board to performance improvement plans toward improving healthcare delivery?

Management should not expect that employees share their desire for change when the organizations are not performing well. Nor should management create teams and expect those teams to produce changes without providing the context for that change. Effective performance improvement does not start with solutions that are prescriptive and instructional; however, it should start with shared diagnosis and mutual engagement involving all employees that result in shared values and collaboration. These in turn help build the organization’s culture toward long term success and not just temporary fixes. High levels of employee commitment result in higher productivity, creativity, and collaboration. This, in turn, creates successful performance improvement programs.

According to Bert Spector, scholar and author in organizational change management and Director for Emerging Executives for the Federal Bureau of Investigation, these five elements create high commitment among employees when implementing performance improvement:

  1. Clarity of the organization goals by employees at all levels,
  2. Teamwork
  3. Shared Information
  4. Organic Controls
  5. Individual development opportunities

Employee communications play a significant role in the success or failure of any major performance improvement or change program. Management needs to get feedback from their employees, and employees need to have a safe environment in which to give that feedback. A good understanding of theories for effective performance improvement (especially those that deal with employee motivation) is a crucial step in improving healthcare delivery.

References:

Spector, B., (2013), Implementing Organizational Change: Theory into Practice, 3rd ed., Upper Saddle River, New Jersey: Pearson, pp. 51-98.

Barrett, D. J. (2002). Change communication: Using strategic employee communication to facilitate major change. Corporate Communications, 7(4), 219-231.

 

Information on policies or practices are solely from my personal experience ONLY and have NO relation to my affiliation with any regulatory or government agency.

satyadi

-Caroline Satyadi, MT(ASCP), SM, DLM, SLS, MBA, MS, CQA (ASQ) has been a laboratory management professional for over 25 years. She has worked with several different medical industries for CLIA/CMS, FDA/ICH/ISO, TJC/CAP/COLA/HFAP accreditation survey readiness.

 

My 3Ts: Trials and Tribulations of Technology!

Like so many others, I figured it wouldn’t happen to me. Like countless others, I have been through the fires of Hades trying to straighten out a “hacked” email account. Like numerous others, I’ve come away from the experience knowing more and enjoying less of my techno-challenged universe! Changing your email address is about as complicated as changing your DNA. Consider, it’s not just closing down “yahoo” and opening up “gmail.” It’s re-capturing the twenty-year list of professional and personal contacts that were compromised and will never be found again. Or the list of archived documents that hold the history of your collective files, reference materials, all the “stuff” you keep. Never mind the cartoons and pictures…I gave up on those long ago.

After my gnashing of teeth and ultimate resolve to fix the issue, it occurred to me what a huge problem it would be to re-create a “hacked laboratory.” In the laboratory, it would be like wiping out every send-out log, every result, every known micro or blood bank patient history, every phlebotomy encounter, and every patient demographic that exists. Well, you get the picture! It’s a “do over” at the highest level. Back-up and clouds aside, it would be very difficult. What computers have done FOR us is to standardize and streamline data collection, improve error rates, and decrease turnaround times for diagnoses, test results and treatment. All VERY good things. I would also propose that….if a process is broken or not working, adding computerized technology only speeds it up and makes it go really really fast….it doesn’t fix the process! Technology is an enabler, and should be used to enhance where needed. As laboratory professionals, in addition to learning the skills of “medical technology”, we are also rely on LIS systems, HIS integrations, and the other “non-medical technologies” that make our systems more efficient. I encourage us all to remember that we must also focus first on improving our processes, so that when they go fast, they also go well. Having someone hack my email forced me to look at my processes…and indeed, some of them were going fast but needed improvements!

Technology is what we do. Technologist is in our title and licensure. It seems to me that science geeks, which most of us are, weren’t prepared to be computer geeks as well….and therein lies the hope for an even better next generation of “medical technologists.” Are we indeed still medical, still seeking continuous improvement and quality processes for our patients, or are we just highly computerized technology teams who can deliver results really fast? Something to ponder…

Cheers!

 

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Beverly Sumwalt, MA, DLM, CLS, MT(ASCP) is an ASCP Global Outreach Volunteer Consultant.

Halfway Through…and What’s Left to Do

I had originally started writing about a recent article I read on residents organizing as a collective bargaining unit for salary negotiations. But I’ll leave that for another day and give you a more informal blog post today.

So, for those of you who don’t know, I will be transferring to a program in my home state of NJ for personal reasons for my last two years. When I initially applied to residencies, I didn’t apply to any of the three programs in NJ because I wanted to be in a large (>4 residents/year), urban program that served a significant number of underserved minority and immigrant patients. Chicago was a familiar choice as I had attended college at The University of Chicago alongside my brother here many moons ago. It was also where I first began working with minority and immigrant community advocacy and grassroots organizing groups and my oppas (“older brothers”) and unnis (“older sisters”) then, are the leaders of these groups now.

But two years later, circumstances in my life change, priorities change, and the reasons to go home were more compelling than those to stay. It wasn’t an easy decision. My chairman and attendings here have been very supportive, especially of my extracurricular activities and research. I know that when I go to fellowship interviews, people will ask why I transferred. The reasons are innocent and legitimate enough but I do wonder if they may affect how programs will view me as a potential candidate when they hear my reasons. After all, fellowships are more competitive to obtain than residencies and any small possibly of negative perception, whether true or erroneous, can make or break whether you get those fewer positions available.

I took this week off to deal with moving tasks and my apartment is a mess of half-packed boxes. I need to get as much done before I’m back at our busiest surgpath site again next week until I leave for NJ. But the déjà vu act of packing, calling up moving companies for quotes, and selling items in order to lighten my load has put me in a contemplative mood. I realize that now I am almost halfway through this part of my journey to become a practicing pathologist.

Sometimes, I feel as if I have been weighed and measured and found wanting in terms of where I should be in AP. With my research and heavy science background, CP has always been a comfortable fit. I haven’t had any cytology rotations yet but I get to do four months in NJ. In terms of surgpath, I’m knowledgeable enough with the “bread and butter” that I see during sign-outs but not knowledgeable enough when it comes to unknowns. I know I should read more and often wonder why I don’t do as much as I could.

But now that I’ve come to this fork in my journey, moving back to NJ and thinking about applying for my first fellowship, I wonder what do I need to become the best pathologist I can with the time I have left? I don’t want to be cramming everything I should’ve learned in three years into my last year when boards studying fever hits. If anyone has some advice or anecdotes about their training to illustrate something that is working for them, please feel free to share.

And yet, even though our studies and service duties are, of course very important, how should we engage in molding our profession into the pathology of the next age? What are the most salient skills we need to acquire and how do we show the clinical care teams that are evolving within healthcare reform just where our place is within it? What are the most pressing issues for residents? Salaries, autonomy to influence our education, didactics, service duties, or clinical care? Where should we most focus our efforts?

 

Chung

Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.