Just Culture Application – Event Investigation Part 2 “Rules of Causation”
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Transcript of Just Culture Application – Event Investigation Part 2 “Rules of Causation”
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Just CultureApplication – Event Investigation
Part 2“Rules of Causation”
Stephanie SobczakQuality Improvement Manager
WHA
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Welcome New Teams!Jill and Stephanie will host a special conference
call for new Just Culture teams for an orientation to the initiative and Q & A
April 17, Wednesday @ NoonCall: 1-800-747-5150
Code: 29766
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Just Culture Teams
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Wave 1
Aspirus Wausau
Baldwin Area Medical Center
Fort Healthcare
Gunderson Lutheran
Langlade (Antigo)
Memorial Health Cntr (Medford)
Riverside Medical Center
Sacred Heart (Eau Claire)
Sauk Prairie
St. Joseph’s (Chippewa Falls)
UWHP Watertown
Wave 2
Aurora Medical Center (Kenosha)
Holy Family (Manitowoc)
Hudson Hospital
Rusk County Memorial (Ladysmith)
Upland Hills Health (Dodgeville)
“Monitoring”
Beaver Dam Community
Black River Memorial
Calumet Medical Center (Chilton)
Edgerton Hospital
Mercy Hospital (Janesville)
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Today’s CallApplication – Event Investigation – Part 2• Event Investigation – brief review• Examining Types of Causes• Understanding Rules of Causation• Case Examples• Next 30 days
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Please be certain your phone lines are muted or computer speakers turned down to allow for open discussion on the phones
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Past 30 DaysACTION ITEMS
Continue to send in your scenario examples (for our Spring webinar discussions)
Develop your training plan
Identify what your staff role and expectations will be regarding your fair and just culture
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Event Investigation Review
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The Basics of Event Investigation
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Increasing value
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The Basics of Event InvestigationUnderstanding the link between the outcome
and behavioral choices• Explain human errors
– What performance shaping factors impact these?• System• Personal Performance
• Explain at-risk behaviors– Why was the decision made?– How prevalent is the behavior?
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Reviewing Your Existing Processes
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Increasing value
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Event InvestigationWhat is the role of event investigation in the management of risk?
Single Event:
• To Explain
• To Predict
• To Solve
• To Allocate Responsibility
Systemic Investigation:
• To inform the organization of dominant risks, causal failure modes, and rates
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Common Traps
Guessing or Assuming
“I’ve seen this before….”
Not doing an investigation
Not talking directly to the people involved
Arriving at a conclusion too early
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Examining Types of Causes
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Cause vs. Correlation
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5 Rules of Causation
1. Causal Statements must clearly show the ‘cause and effect’ relationship
2. Negative descriptors may not be used in causal statements
3. Each human error should have a preceding cause
4. Each ‘at-risk’ behavior/violation, or procedural deviation, should have a preceding cause.
5. Failure to act is only causal when there was a pre-existing duty to act.
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Case Study Review
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Causal Diagram Process
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Case A - Housekeeping Example
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Case B – Central Venous Catheter
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Group Discussion
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Event Investigation Hands On Practice Example
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Prior to May 1 webinar Using an in-house scenario, have your JC
team walk thru an event investigation process using what you have learned
Be prepared to share with the group what insights you discovered as a result.
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The Next 30 DaysACTION ITEMS
Assess your current event investigation processes
Using an in-house scenario, have your JC team walk thru an event investigation process; be prepared to discussPlease send a scenario examples (for our Spring webinar discussions)
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Thank You!Questions?
May 1st Just Culture Webinar10-11 am
Coaching At-Risk Behavior
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