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. 2017 May 25;2(3):e025.
doi: 10.1097/pq9.0000000000000025. eCollection 2017 May-Jun.

Improving Apparent Cause Analysis Reliability: A Quality Improvement Initiative

Kristen M Crandall  1 , May-Britt Sten  1 , Ahmed Almuhanna  1 , Lisbeth Fahey  1 , Rahul K Shah  1
Affiliations

Improving Apparent Cause Analysis Reliability: A Quality Improvement Initiative

Kristen M Crandall et al. Pediatr Qual Saf. .

Abstract

Introduction: Apparent cause analysis (ACA) is a process in quality improvement used to examine events. A baseline assessment of completed ACAs at a tertiary care free-standing pediatric academic hospital revealed they were ineffective due to low-quality analysis, unreliable action plans, and poor spread, leading to error recurrence. The goal of this project was to increase ACA action plan reliability scores while maintaining or decreasing turnaround time.

Methods: The Model for Improvement served as the framework for this quality improvement initiative. We developed a key driver diagram, established measures, tested interventions using plan- do-study-act cycles, and implemented the effective interventions. To measure reliability, we created a high reliability toolkit that links each action item/intervention to a level of reliability and scored each ACA action plan to determine overall reliability score. Action plans scored as low level of reliability required revision before implementation.

Results: Average ACA action plan reliability scores increased from 86.4% to 96.1%. ACA turnaround time decreased from a baseline of 13 days to 8.6 days. Stakeholders reported a subjective increase in satisfaction with the revamped ACA process.

Conclusions: Incorporating high reliability principles into ACA action plan development increased the effectiveness of ACA while decreasing turnaround time. The high reliability toolkit was instrumental in providing an organizational resource for approaching this subset of cause analyses. The toolkit provides a way for safety/quality leaders to connect with stakeholders to design highly reliable solutions that improve safety for patients, families, and staff.

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Figures

Fig. 1.
Fig. 1.
Key Driver Diagram for Improving ACA Reliability quality improvement project.
Fig. 2.
Fig. 2.
Plan-do-study-act cycles for Improving ACA Reliability quality improvement project.
Fig. 3.
Fig. 3.
ACA Reliability outcome measure x-bar chart.
Fig. 4.
Fig. 4.
ACA turnaround time balancing measure x-bar chart.
See this image and copyright information in PMC

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References

    1. Hettinger AZ, Fairbanks RJ, Hegde S, et al. An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions. J Healthc Risk Manag. 2013;33:11–20.. - PMC - PubMed
    1. Solutions for Patient Safety. Apparent Cause Analysis & Common Cause Analysis. 2015Online: Children’s Hospitals’.
    1. Apparent Cause Analysis for Healthcare. 2008Norfolk, Va.: Healthcare Performance Improvement.
    1. Wu AW, Lipshutz AK, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA. 2008;299:685–687.. - PubMed
    1. Wagner C, Merten H, Zwaan L, et al. Unit-based incident reporting and root cause analysis: variation at three hospital unit types. BMJ Open. 2016;6:e011277. - PMC - PubMed

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