lesson 3: Problem Identification Flashcards
What is root cause analysis?
- focuses on the process rather than the people
- swiss cheese model of system failure
- Five whys
- use the fishbone diagram
What are errors people can make?
- forgetfulness
- inattention
- poor motivation
- carelessness
- recklessness
- negligence
- moral issues: bad things happen to bad people
What are examples of counter measures to these human errors?
- poster campaigns
- naming and shaming
- litigation
- more policies
- retraining
- supervision
What is reason’s swiss cheese model?
- humans are fallible and errors are to be expected
- build systems that catch errors
- explore the system to understand how the error or near miss occurred
- create a blame-free reporting culture
- defensive layers are imperfect so build multiple
- weaknesses in defences are not stable
What are the 3 stages of the just do it model?
- just do it
- root cause
- A3
State the levels of analysis required for each stage of the just do it model?
- Just do it: no analysis needed
- Root cause: some analysis needed
- A3: team work and collaboration needed
List different features of the low effort just do it.
- high level of understanding
- well informed solution
- minimal effort
- team not needed
- stakeholders agree on solution
- easy
- example: team members are not aware of new process so need to train them
What level of effort can be assigned to each stage of the just do it model?
- Just do it- low effort
- root cause analysis: medium effort
- A3 project: high level of effort
List different features of the medium effort root cause analysis
- medium understanding
- root cause not known
- no solution
- medium effort
- may need a team
- stakeholders need more information
- medium
- example: one patient left without being seen
List different features of the high effort A3 project
- low understanding
- root cause not known
- no solution
- high effort
- requires a team
- stakeholders need more information
- difficult
- example: reduce length of stay post-anthroplasty
how many steps are there in the A3 problem solving tool developed by toyota
9 (0-9)
list the 9 steps of the A3 problem solving tool developed by toyota
- identify the problem
- capture the current state of the situation
- conduct a root cause analysis
- devise counter measures to address root causes
- define your target state/desire outcome/ standard
- develop a plan for implementation
6.develop a follow up plan with predicted outcomes - get everyone on board
- implement
- evaluate results
How do we define ‘a problem’
- comparative benchmarking
- significant event analysis/ critical incident analysis/ root cause analysis
- complaints and feedback data
- research: patient reported outcome measures
What is a service audit?
- how well is the service doing in terms of meeting its aims so evaluation of current practice
- used for quality improvement purposes
- creation of information to inform management decision
- doesn’t need ethical approval but should consider ethical issues
What is an audit?
- measuring the care we deliver against a gold-standard benchmark like evidence based practice standards
- used for quality improvement purposes and can be done locally or nationally
- doesn’t need ethical approval but should still consider ethical issues
What is research?
generation of new knowledge
What do you need for comparative benchmarking?
- trustworthy data
training and employment of data co-ordinators - mechanisms to retrieve data
- quality assurance of collected data
- well defined data collection processes
- ongoing operational support between audit participants and audit office
What does the define section entail?
- what is a problem to you or your organisation
- why is it a problem
- who is it a problem for
- can you quantify or qualify the problem
- process map, fishbone diagram
What does the diagnose section entail?
- look for errors in the system that contribute to the problem
- focus on system not individuals- swiss cheese
- 5 whys
- appreciative enquiry
What does the design section entail?
- driver diagram
- stakeholder mapping
- planning
What does the deliver section entail?
- test your solution
- embed and disseminate
