Root Cause Analysis in Health Care: Tools and Techniques, 6th Edition
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U.S. Standards

Root Cause Analysis in Health Care: Tools and Techniques, 6th Edition

Address patient safety events head on and get help to further your understanding of root causes for errors!

Release Date: October 2017. 186 pages.

  • An individual license is intended for single users only. This ebook cannot be shared, disseminated, downloaded, or posted for widespread or public use. 
  • site license allows this ebook to be shared among unlimited users but only within one facility or site, either by posting to a secure intranet site or by providing other means of secure access. 
  • system license allows this ebook to be shared among unlimited users within all facilities or sites within a health care system, either by posting to a secure intranet site or by providing other means of secure access. Please contact JCR Customer Service (877.223.6866 option 1) for pricing of a system license.

$89.00 - $219.00
Product Description

Product Description

When a serious patient safety event occurs, the health care organization must identify and examine the system failures or defects that contributed to the event to guard against future reoccurrences. Root cause analysis (RCA) provides a systematic approach to identify these contributing factors. In the specific case of a sentinel event, The Joint Commission requires accredited organizations to perform a comprehensive systematic analysis. However, RCA also can be used as a proactive tool to identify potential safety problems before they reach a patient. This book includes examples that guide the reader through application of root cause analysis to the investigation of specific types of sentinel events, such as medication errors, suicide, treatment delay, and elopement. 
Root Cause Analysis in Health Care: Tools and Techniques, 6th edition, provides updated statistics and introduces new concepts and tools associated with RCA2: Improving Root Cause Analyses and Actions to Prevent Harm, the National Patient Safety Foundation’s in-depth report focusing on the techniques and processes of how root cause analyses can best prioritize system flaws and vulnerabilities and make improvements to successfully improve patient care in all health care settings. This book also includes new and revised tools aligned with the Joint Commission’s Robust Process Improvement® (RPI®), a set of process improvement strategies adopted by The Joint Commission to help organizations improve business processes and clinical outcomes.
Key Topics:
  • Overview of root cause analysis and how it is used both proactively and as a response to a sentinel event
  • Addressing sentinel events in policy and practice
  • Preparing for a root cause analysis
  • Determining proximate and root causes
  • Designing and implementing a corrective action plan for improvement
Key Features:
  • A framework with 24 analysis questions for conducting an effective RCA
  • Checklists and worksheets for applying the framework (included on a flash drive for print version or linked in the e-book)
  • Tools and techniques used in root cause analysis
Key Audience:
  • Accreditation and compliance managers
  • Clinical department heads
  • Patient safety officers
  • Quality improvement staff
  • Risk managers

Joint Commission Resources, Inc. (JCR), a wholly controlled, not-for-profit affiliate of The Joint Commission, is the official publisher and educator of The Joint Commission.

JCR is an expert resource for health care organizations, providing advisory services, educational services and publications to assist in improving quality and safety and to help in meeting the accreditation standards of The Joint Commission. JCR provides advisory services independently from The Joint Commission and in a fully confidential manner.

Table of Contents

Table of Contents

Chapter 1: Root Cause Analysis: An Overview
  • Investigating Patient Safety Events: The Need for Comprehensive Systematic Analysis
  • RCA2 in High Reliability Industries
  • When Can a Root Cause Analysis Be Performed? 
  • Variation and the Difference Between Proximate and Root Causes
  • Benefits of Root Cause Analysis
  • Maximizing the Value of Root Cause Analysis
  • The Root Cause Analysis and Corrective Action Plan: Doing It Right
Contents of flash Drive
  • Framework for Root Cause Analysis and Action Plan
  • Root Cause Analysis Evaluation Checklist
Chapter 2: Addressing Sentinel Events in Policy and Strategy
  • The Range of Adverse Events in Health Care
  • Signals of Risk: Close Calls and No Harm Events
  • The Joint Commission’s Sentinel Event Policy
  • Reasons for Reporting a Sentinel Event to The Joint Commission
  • Required Response to a Sentinel Event
  • Joint Commission International’s Sentinel Event Policy
  • Related Joint Commission International Standards
  • Developing Your Own Sentinel Event Policy
  • Leadership, Culture, and Patient Safety Events
  • Early Response Strategies
  • Event Investigation
  • Onward with Root Cause Analysis
  • Sentinel Event Notification Checklist
Chapter 3: Preparing for Root Cause Analysis
  • Step 1 Organize a Team
  • Step 2 Define the Problem
  • Step 3 Study the Problem
  • Key Steps in Root Cause Analysis and Improvement Planning
  • Composing the Team
  • Defining the Problem
  • Preliminary Planning
  • Gathering Information
Chapter 4: Determining Proximate Causes
  • Step 4 Determine What Happened
  • Step 5 Identify Contributing Process Factors
  • Step 6 Identify Other Contributing Factors
  • Step 7 Measure—Collect and Assess Data on Proximate and Underlying Causes
  • Step 8 Design and Implement Immediate Changes
  • Gannt Chart
  • Prioritizing Improvement Actions
  • Further Defining What Happened
  • Identifying Proximate Causes
  • Identifying Factors Close to the Event
Chapter 5: Identifying Root Causes
  • Step 9 Identify Which Systems Are Involved—The Root Causes
  • Step 10 Prune the List of Root Causes
  • Step 11 Confirm Root Causes and Consider Their Interrelationships
  • Defining Improvement Goals Scope Activities
  • Probing for underlying causes
  • Problematic Systems or Processes
Chapter 6: Designing a Corrective Action Plan for Improvement
  • Step 12 Explore and Identify Risk-Reduction Strategies 
  • Step 13 Formulate Improvement Actions
  • Step 14 Evaluate Proposed Improvement Actions 
  • Step 15 Design Improvements
  • Step 16 Ensure Acceptability of the Corrective Action Plan
  • Step 17 Implement the Improvement Plan
  • Step 18 Develop Measures of Effectiveness and Ensure Their Success
  • Step 19 Evaluate Implementation of Improvement Efforts
  • Step 20 Take Additional Action
  • Step 21 Communicate the Results
  • Prioritizing Improvement Actions
  • Summarizing the Potential of Improvement Actions
  • Defining Improvement Expectations, Sequence, Resources, and Measures
  • Defining Time Frames and Milestones
  • Involving the Right People
  • Determining the Location of Improvement Actions
  • Integrating the Improvement Plan
  • Identifying Change Barriers and Solutions
  • Designing the Measurement Plan
  • Evaluating Target Goals
Chapter 7: Addressing Sentinel Events in Policy and Strategy
  • What is RPI®?
  • What Is Lean Six Sigma?
  • Affinity Diagram
  • Brainstorming
  • Change Analysis
  • Change Management
  • Check Sheet
  • Control Chart
  • Failure Mode and Effects Analysis (FMEA)
  • Fishbone Diagram
  • Flowchart
  • Gantt Chart
  • Histogram
  • Multivoting
  • Operational Definition
  • Pareto Chart
  • Relations Diagram
  • Run Chart
  • Scatter Diagram
  • SIPOC Process Map
  • Stakeholder Analysis
  • Standard Work
  • Value Stream Mapping
CHAPTER 7: Tools and Techniques
  • Affinity Diagram


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