decision to do an rca va national center for patient safety rev.02.26.2015 1 the rca process an...
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 1
The RCA ProcessAn Overview
The RCA Process an Overview
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 2
Flow Chart Process Guide
RCA Team Process
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 3
Decision to do an RCA
RCA Team Process 3
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 4
Immediate Actions
As Required
RCA Team Process 4
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 5
Charter/Appoint Team
RCA Team Process 5
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 6
Decision to do an RCA
Just in Time Training for
Team
RCA Team Process 6
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 7
Decision to do an RCA
Establish Sequence of Events
(First Draft)
RCA Team Process 7
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 8
Decision to do an RCA
IdentifyInformation Gaps
RCA Team Process 8
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 9
Specify Information Required/Who is
Responsible to Get It/ Timeline for Acquiring
RCA Team Process 9
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 10
Use Triage Questions and
RC/Contributing Factor Interview Tools to Frame
Questions
RCA Team Process 10
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 11
Conduct Fact Finding Interviews,
Chart Reviews, and Literature Reviews
RCA Team Process 11
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 12
Synthesize Information
Acquired and Review Using
‘Triage Questions’ and Other Resources
RCA Team Process 12
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 13
Synthesize
Frame Questions
Fact Finding
Information Needed
As Needed
RCA Team Process 13
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 14
Final Version of Sequence
of Events
RCA Team Process 14
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 15
Identify Root Cause/ Contributing Factors
RCA Team Process 15
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 16
Decision to do an RCA
Identify Corrective Actions That Were Instituted
Due to a Similar Event in the Past
RCA Team Process 16
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 17
Develop Action Plan (First Draft)
RCA Team process 17
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 18
Provide Feedback
to Reporter
RCA team Process 18
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 19
Identify What was Learned and Who Needs
to Know
RCA team process 19
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 20
Create Action Planfor Director Concur/
Non-Concur
RCA Team Process 20
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 21
Iterate and Record as Necessary
RCA team process 21
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 22
Determine Approximate Cost
of RCA
RCA team Process 22
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 23
Final RCA and Action Plan
Sign-Off
RCA Team Process 23
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 24
RCA Advisor Conducts Follow-Up
RCA Team Process 24
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Decision to do an RCA
VA National Center for Patient Safety REV.02.26.2015 25
Thank You!
RCA Team Process Thank You