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Occurrence Reporting: Building a Robust Problem Identification and Resolution Process

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Occurrence Reporting: Building a Robust Problem Identification and Resolution Process

Kenneth Rohde    

Enhance patient care through effective occurrence reporting

You already capture the data. Now use it to make real improvements in your patient care.

This new resource by performance improvement expert Kenneth R. Rohde provides practical techniques to help you better analyze your occurrence reporting process, use your data to gain superior insight into why errors occur at your organization, and make improvements that decrease adverse events and enhance patient care.Benefits:

  • Refine and improve your existing occurrence reporting system using a proven six-step approach
  • Arm yourself with the right data to become an effective change agent in your organization
  • Develop an occurrence reporting process that decreases adverse events and enhances patient care
  • Improve your report screening process
  • Easily identify trends through detailed, efficient analysis methods
  • Organize and prioritize your reports through effective coding
  • Implement successful corrective actions through ongoing tracking and evaluation
Table of Contents:

Chapter 1: Rethinking the Occurrence Reporting Process

Where Does Healthcare Go Wrong?

Healthcare Is Not the Only Industry That Does Problem Identification and Resolution (PIR)

Recommendations for an Ideal Process

Chapter 2: The PIR Process

Introducing the PIR Process

Six Steps in the PIR Process

Chapter 3: Reporting

Importance of Managing Reporting

Volume and Severity Must Dance Together

Reporting Thresholds

Tips for Normalization

Internal vs. External Identification of Issues

Two Simple Goals for Reporting Volume

Tips for Improving Your Reporting

Chapter 4: Screening

Screening Is Really Just Prioritization

Establishing Screening Criteria

Reporting Severity

Screening Quality Control

Tips for Improving Your Screening

Chapter 5: Analysis

A Graded Approach to Problem Analysis

Individual Analysis for High-Impact Problems and Moderate-Impact Problems

Aggregated Analysis for Watch/Trend Problems

Aggregated Analysis of Causes: The Big Payoff

Five Simple Data Questions

Trending and Aggregation Methods

A Typical Analysis Session

What Do Your Department Managers Really Want to Know?

Chapter 6: Coding

The Vital Process of Coding

Code Based on Data Utilization

A Practical Coding Structure

Coding the Event vs. Coding the Causes

Initial Event Codes

Code Cleanup Troubleshooting

Tips to Improve Coding

Chapter 7: Causing Change: Implementing Corrective Actions

Designing the Right Change

Getting Stuff Done

Dealing With External Commitments

Tips to Improve Implementation

Chapter 8: Tracking and Evaluation

Tracking Actions

Evaluation of Actions

Evaluating the Effectiveness of the PIR Process

Chapter 9: Taking Your PIR Process to the Next Level

Looking Toward the Future

Look at the 90 occurrence reporting tools included!

  • Aviation Safety Reporting System incident report excerpt
  • National Transportation Safety Board incident report excerpt
  • FDA adverse event report sample
  • IAEA initiation report sample
  • CPSC incident report
  • Quick guide to avoiding weaknesses: Build strengths in your PIR process
  • Six steps of the PIR process
  • Self-assessment questions to evaluate reporting, screening, analysis, coding, implementation, and tracking and evaluation
  • Reporting stability
  • Self-reporting
  • Reporting by department
  • Combine volume and severity to get the best picture
  • Example: Calculating relative activities for use in normalization
  • Tips for improving your reporting
  • Screening helps us know what to do next
  • Screening work flow
  • Expectations for screening
  • Example of converting word severity scales to numerical scales
  • Prioritizing performance improvement activity and corrective actions
  • What we need to know to screen an issue
  • Which issues should we check the severity on?
  • NCC MERP Index for Categorizing Medication Errors
  • Comparison of severity scales
  • Significant event management process
  • Model screening matrix
  • Typical notifications worksheet
  • Balance your analysis efforts
  • Analysis work flow
  • Root cause analysis work flow
  • Expectations for the ideal root cause analysis team, and team sponsor
  • Expectations for an ideal apparent cause analysis
  • Typical fields in a significant event database
  • Significant event database flow chart
  • Five simple questions our data analysis must answer
  • Tools to help answer the magnitude question, the direction question, and the variability question
  • Highly variable data set example
  • Tools to help answer the rate of change question
  • Key considerations for effective time series graphs
  • Time series analysis of reporting volume and harm events
  • Data fields for top-level time series graph
  • Histogram analysis of events by process (one dimension) and event category (two dimensions)
  • Four-quadrant graphs allow you to make easy value decisions
  • Comparison/correlation analysis of volume and severity by department
  • Model agenda for a trend meeting
  • Key ways to improve your analysis
  • Comparison of centralized and distributed coding approaches
  • Coding all causes
  • A practical coding process includes three major types of codes
  • Typical values for “who was impacted”
  • Typical role codes and physical location codes
  • Examples of a process coding approach and an activity coding approach
  • Expectation codes
  • Culture of safety expectations
  • Nature of impact codes
  • Severity codes
  • Moral patient harm severity codes
  • Liability harm severity codes
  • Process impact severity codes
  • When coding is typically performed
  • Table of codes and possible intervention
  • Examples of permanent and transitory corrective actions
  • Typical definitions of qualitative benefits
  • Relationship of permanence and predictability
  • Scope and timing characteristics of corrective actions
  • Checklist for good corrective actions
  • Action plan to prevent recurrence form
  • Feeding the four outputs of action plan
  • Additional coding to support a basic common cause analysis, a basic benefits report, a corrective actions analysis, and to support accountability tracking
  • What can you do with the master action list?
  • Tips for prioritization
  • Alignment of responsibility for the most important corrective actions
  • Quick guide to causing change and implementing corrective actions
  • When should we consider removing a corrective action?
  • Key indicators to evaluate the effectiveness of your PIR process
  • Tracking and evaluation

About the Author

Kenneth R. Rohde is a senior consultant at The Greeley Company. He specializes in the areas of error reduction strategies, root cause analysis, improving performance through process simplification, apparent cause analysis, and failure modes and effects analysis. He brings more than 27 years of experience in quality management to his work with physicians, hospitals, and healthcare organizations across the country.

Product Details

ISBN:
9781601467546
Author:
Rohde, Kenneth R.
Publisher:
Hcpro, a Division of Blr
Subject:
Health and Medicine-Professional Medical Reference
Subject:
General Medical
Edition Description:
Trade Paper
Publication Date:
20110631
Binding:
TRADE PAPER
Language:
English
Pages:
200
Dimensions:
11 x 8.5 in

Related Subjects

Health and Self-Help » Health and Medicine » General
Health and Self-Help » Health and Medicine » General Medicine
Health and Self-Help » Health and Medicine » Practice Management
Health and Self-Help » Health and Medicine » Professional Medical Reference

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