CSH - Event Investigation & Analysis Overview (Self-Paced) -- 2024-2027
Starts On:
07/01/2024: 12:00 AM
Ends On:
06/30/2027: 11:59 PM
Type:
Enduring Material
Location:
CommonSpirit Health
Credits:
0
Description:
** THIS MODULE IS PROVIDED FOR EDUCATIONAL PURPOSES. NO CREDIT IS CURRENTLY BEING OFFERED. **
The goal of this training is to provide an understanding of the purpose for event investigation and analysis and the ability to participate in the activities associated with the CSH Investigation and Analysis process. To help achieve these goals, the framework provides:
- A structure for immediately responding to events, along with a timeline for event reviews.
- An event debriefing process and two additional meetings; with the bulk of the information being gathered prior to bringing the full team together.
- Updated language; including "event investigation and analysis" as a replacement for "root cause analysis," to reflect a systems-based approach with "contributing and causal factors" instead of "root causes."
- Standardized templates for the event investigation and analysis process.
** THIS MODULE IS PROVIDED FOR EDUCATIONAL PURPOSES. NO CREDIT IS CURRENTLY BEING OFFERED. **
The goal of this training is to provide an understanding of the purpose for event investigation and analysis and the ability to participate in the activities associated with the CSH Investigation and Analysis process. To help achieve these goals, the framework provides:
- A structure for immediately responding to events, along with a timeline for event reviews.
- An event debriefing process and two additional meetings; with the bulk of the information being gathered prior to bringing the full team together.
- Updated language; including "event investigation and analysis" as a replacement for "root cause analysis," to reflect a systems-based approach with "contributing and causal factors" instead of "root causes."
- Standardized templates for the event investigation and analysis process.
Objectives:
1. Implement the three meeting model for event investigation and analysis within 24 hours.
2. Identify and incorporate the components of the CSH Event Investigation and Analysis into practice.
3. Engage senior leaders fully in the event investigation and analysis process as evidence by documentation on the action plan within 24 hours of the event occurring.
TO SUCCESSFULLY COMPLETE THIS COURSE
To successfully complete this activity the learner must watch all of the videos, review the associated materials, complete the post-test with an 80 % proficiency, and submit the evaluation.
References
Leape LL. Testimony, United States Congress, House Committee on Veterans' Affairs, October 12, 1997.
Apply CUSP module, CUSP Toolkit. Rockville, MD: Agency for Healthcare Research and Quality. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/modules/apply/index.html. Accessed August 8, 2015.
Guide to Patient and Family Engagement in Hospital Quality and Safety. Rockville, MD. Agency for
Healthcare Research and Quality. http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies. Accessed July 21, 2015.
Carman KL ,et al. A Roadmap for Patient and Family Engagement in Healthcare Practice and Research.
Gordon and Betty Moore Foundation. Palo Alto, CA; September 2014. http://patientfamilyengagement.org/#sthash.HZNslZP1.WpGsc2si.dpuf. Accessed July 21, 2015.
Parker SH, Krevat SA, Morales CL, Fairbanks RJ. System-Focused Event Investigation and Analysis
Guide. Columbia, MD: MedStar Health. Washington DC: Georgetown University.
Mello MM, et al. Communication-and-resolution programs: the challenges and lessons learned from six early adopters. Health Affairs. 33.1 (2014): 20-29. http://content.healthaffairs.org/content/33/1/20.full.pdf+html. Accessed September 10, 2015
Boothman, R and Hoyler MM. The University of Michigan's early disclosure and offer program. Bulletin of the American College of Surgeons. 98.3 (2013): 21-25. http://bulletin.facs.org/2013/03/michigans-early-disclosure/. Accessed August 21, 2015.
CANDOR System-Focused Event Investigation and Analysis Guide https://www.ahrq.gov/patient-safety/capacity/candor/modules/guide4.html
RCA2 Improving Root Cause Analyses and Actions to Prevent Harm, https://www.ashp.org/-/media/assets/policy-guidelines/docs/endorsed-documents/endorsed-documents-improving-root-cause-analyses-actions-prevent-harm.ashx
VA National Center for Patient Safety TM Root Cause Analysis (RCA), https://www.state.nj.us/health/healthcarequality/documents/ps/va_triage_questions.pdf
Disclosure Information: No one on the planning team or faculty have any relevant financial relationships with commercial interests.
1. Implement the three meeting model for event investigation and analysis within 24 hours.
2. Identify and incorporate the components of the CSH Event Investigation and Analysis into practice.
3. Engage senior leaders fully in the event investigation and analysis process as evidence by documentation on the action plan within 24 hours of the event occurring.
TO SUCCESSFULLY COMPLETE THIS COURSE
To successfully complete this activity the learner must watch all of the videos, review the associated materials, complete the post-test with an 80 % proficiency, and submit the evaluation.
References
Leape LL. Testimony, United States Congress, House Committee on Veterans' Affairs, October 12, 1997.
Apply CUSP module, CUSP Toolkit. Rockville, MD: Agency for Healthcare Research and Quality. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/modules/apply/index.html. Accessed August 8, 2015.
Guide to Patient and Family Engagement in Hospital Quality and Safety. Rockville, MD. Agency for
Healthcare Research and Quality. http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies. Accessed July 21, 2015.
Carman KL ,et al. A Roadmap for Patient and Family Engagement in Healthcare Practice and Research.
Gordon and Betty Moore Foundation. Palo Alto, CA; September 2014. http://patientfamilyengagement.org/#sthash.HZNslZP1.WpGsc2si.dpuf. Accessed July 21, 2015.
Parker SH, Krevat SA, Morales CL, Fairbanks RJ. System-Focused Event Investigation and Analysis
Guide. Columbia, MD: MedStar Health. Washington DC: Georgetown University.
Mello MM, et al. Communication-and-resolution programs: the challenges and lessons learned from six early adopters. Health Affairs. 33.1 (2014): 20-29. http://content.healthaffairs.org/content/33/1/20.full.pdf+html. Accessed September 10, 2015
Boothman, R and Hoyler MM. The University of Michigan's early disclosure and offer program. Bulletin of the American College of Surgeons. 98.3 (2013): 21-25. http://bulletin.facs.org/2013/03/michigans-early-disclosure/. Accessed August 21, 2015.
CANDOR System-Focused Event Investigation and Analysis Guide https://www.ahrq.gov/patient-safety/capacity/candor/modules/guide4.html
RCA2 Improving Root Cause Analyses and Actions to Prevent Harm, https://www.ashp.org/-/media/assets/policy-guidelines/docs/endorsed-documents/endorsed-documents-improving-root-cause-analyses-actions-prevent-harm.ashx
VA National Center for Patient Safety TM Root Cause Analysis (RCA), https://www.state.nj.us/health/healthcarequality/documents/ps/va_triage_questions.pdf
Disclosure Information: No one on the planning team or faculty have any relevant financial relationships with commercial interests.
Contact Information:
For any questions related to this educational activity or difficulty obtaining your Continuing Education Certificates or Transcripts, please email [email protected]
For any questions related to this educational activity or difficulty obtaining your Continuing Education Certificates or Transcripts, please email [email protected]