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Enhanced RCA Methodologies
Most sentinel events are attributable to human error. Causes of errors are manifold and often include complex human factors issues such as system design and organizational processes rather than individual incompetence. Therefore, any Root Cause Analysis (RCA) of a sentinel event cannot be considered “thorough and credible” unless it effectively examines the human factors that underlie errors that caused patient harm.
Ironically, current RCA methods, which are now mandated by the Joint Commission for all sentinel events, were NOT designed to identify human factors causes of errors. Rather, RCA is an engineering method designed to discover the causes underlying equipment and material failures. Thus, when RCA methods are used to analyze human factors, they typically produce superficial results, often focusing on “who did what” rather than on “why” an error occurred.
This paradox is a significant patient safety issue. Major concerns exist regarding the ability of traditional RCA methods to identify human factors issues or to generate effective corrective solutions to such problems. If healthcare is to become safer, a more “thorough and credible” RCA process for analyzing and correcting the most common causes of sentinel events (i.e., human factors) needs to be deployed.
The Human Factors Analysis and Classification System (HFACS) was designed to address this critical need. HFACS is an innovative methodology for conducting a comprehensive human factors analysis of sentinel events associated with human error. The HFACS method was originally developed by our team to facilitate the analysis of human factors associated with aviation accidents. It is based upon Reason’ s “Swiss Cheese” model of accident causation, which conceptualizes human error as the product of complex interactions among myriad latent and active system variables.
HFACS translates Reason’s theory into practice via a pragmatic framework or tool that systematically guides the process of collecting information, interviewing witnesses, and analyzing human factors data associated with adverse events. Since it original development for aviation, HFACS has been successfully applied across a variety of high-risk industries including healthcare. It has undergone extensive usability testing. Numerous studies by our team and others have shown HFACS to be a reliable analysis tool that can lead to effective corrective actions for reducing the recurrence of adverse events.
Innovative Performance Improvement Strategies
People often have difficulty discovering new was of solving a problem. They may also feel uncomfortable thinking “outside their box.” As a result, they may limit their approach, focusing on only a very narrow set of options. Other times, people tend to look for “the best way” to attack an issue, hoping to find the one “silver bullet” that will completely eliminate the problem. However, such panaceas rarely exist. In their search for this illusive “best” solution, other opportunities for intervening are often ignored or overlooked.
The best approach for generating innovative ideas to solve a problem is to first come up with as many possible solutions as possible. However, a large number of solutions is not enough. Solutions should also address the problem from a variety of different approaches or perspectives. In other words, interventions need to attack the same problem from many different angles.
The HUMAN FACTORS INTERVENTION MATRIX (HFIX) is designed to help you accomplish these goals. Specifically, HFIX consists of a series of probes or questions that help you uncover multiple interventions to address a problem. The questions are also grouped around specific approaches to improving safety based on the HFACS-RCA framework. As result, HFIX facilitates the generation of a greater variety of approaches to attacking the same problem. The result is a more comprehensive list of possible solutions to choose from.
The next step, then, is to determine which ones of the numerous possible interventions should be recommended for implementation. To accomplish this goal, HFIX contains a method for evaluating each intervention using a set of criteria called FACES: Feasibility, Acceptability, Cost/Benefit, Effectiveness, and Sustainability. These criteria can be used to generate a final list of your top ideas that are most likely to have a positive impact performance or safety.
Applying the HFIX process will facilitate the identification of multiple innovative strategies that are more likely to be endorsed by leadership and more readily received by those impacted by the change.
Proactive Diagnostic Tools
The best way to enhance performance is to identify and remedy barriers to success before they have a chance to cause problems. Common approaches include the use of near miss reporting systems, failure modes effects analysis (FMEA) and Six Sigma. Unfortunately, much like traditional RCA methods, these approaches are fundamentally engineering methods designed to uncover and help remedy mechanical and technical problems. Consequently, they are often difficult to apply when dealing with complex human factors and performance issues. However, with the integration of the HFACS and HFIX methodologies, these proactive approaches can be transformed into highly effective, proactive diagnostic tools.
Contact us to learn more about how you can use HFACS and HFIX to proactively identifying potential problems associated with human factors issues and generate innovative interventions to improve quality, safety and efficiency in your organization.
The old adage that many industries are “data rich but information poor” still rings true for many modern healthcare organizations. At HFACS, Inc., we can help turn data into information, information into knowledge, and knowledge into effective performance solutions. Our innovative methodologies and advanced analytical techniques can facilitate the identification of common patterns and trends that reflect the latent, system factors that underlie many of your performance barriers. Our advanced software can also help integrate your diverse databases and IT systems to uncover and solve even your most elusive barriers to success. Contact us to learn more about our expert consulting services.
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