RootModelSpec

RootModel Solutions System Analysis
November 11, 2013

Private and Confidential

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RootModel Solutions System Concept
RootModel Solutions is a web based system that will help industry professionals understand adverse events. We will
do this by providing a set of tools that will support the data collection, event sequence, causal analysis, management
review, implementation and the close/review phases of an event investigation.
The system was designed to be a 'software tool' geared toward RCA work-flow as opposed to a 'data collection
system'. This was done because most hospitals already maintain Incident Management systems.
Root Cause Analysis can be either Proactive or Reactive. Proactive RCA focuses on preventing an accident from ever
occurring. It is used in industries that release products or processes and need to know the “what if” scenarios.
Reactive RCA is used to determine what just happened. Though each type shares common tasks, RootModel
Solutions will focus on the Reactive RCA model.

General Goals
• Automation – From the collection of notes to the implementation of Risk Reduction Strategies, there
are many manual processes that need to be automated and standardized.

• Communication – Allowing the investigator to email all team members in a standardized method and
the ability to publish documents in secured directories will open up communication lines and enable a
smooth investigation.

• Implementation – Making changes is no good unless they can be tracked and measured.

• Education – Understanding the process of RCA is essential to a successful investigation. Providing
educational tools that are available to all team members and embedding a 'Coach' to assist in the
investigation will lead to an educated user community.

System Goals

• Provide a set of user-friendly tools to support all phases of incident investigation.

• Provide a work flow process to help guide the user from one phase to the next.

• Maintain all investigation data in a central database.

• Provide the ability to maintain Apparent Cause and Root Cause incident types.

• Apparent Cause incidents do not require a full investigation but the details should be maintained
for legal and historical purposes.

• Root Cause incidents require a full blown investigation and will utilize all the tools available in
RootModel.

• Provide the ability to communicate with Incident Management systems or import a file to create the
initial Incident report and export a file to provide the details of the identified root causes to the Incident
Management systems. It is in these systems where the causal classifications are determined.

• Provide an in-depth education subsystem that maintains predefined and user defined learning videos
and documents.

• Provide a 'Coach' in all phases that helps the user to understand the current phase or to think about the
event in different ways.

• Support the ability to brainstorm and store the brainstorm session.

• Provide a utility to maintain team members and allow communication through email.

• Ability to Print or Save as PDF or Publish to secure directory to any report or document in the system.

• Ability to upload evidence and save it in a secure directory.

• Provide a Team interface that gives team members the ability to get help, fill out progress reports and
score cards.

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User Community
RCA in the health care community is unlike any other. RCA in the nuclear, aviation, transportation and
manufacturing fields use engineer/technical people to perform RCA. These people are trained in methods of
analysis and understand analytical reasoning. The people that perform RCA in health care do not think
like engineers.
In the health care field, a deep understanding of medical practices are required to perform an RCA and the
positions are typically held by nurses that have chosen to peruse patient safety. A lifetime of taking care of
people does not sharpen analytical reasoning skills. Additionally, health care needs to deal with a myriad
of legal issues, federal and local regulations, insurance company rules, changing IT environment, staff
shortages and so much more.
Almost every service healthcare provides can result in an adverse event and leads all other fields in
the number of workplace injuries.
Characteristics of user community.

• Nurses that moved into patient safety.
• Have a deep knowledge of the medical procedures and processes.
• Older and Experienced in the medical field.
• Computer competence can range anywhere from low to very high.
• Inundated with technology systems forcing them to understand multiple systems.
• Overworked and under pressure.

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Current State of Healthcare RCA

Root cause analysis has been around for many years, however the healthcare community began using it in 1999.
According the Institute of Medicine, death rates due to medical errors were estimated to be between 44,000 and
98,000 - more than the death rates of breast cancer, motor vehicle accidents, and AIDS. Death from medical errors
was the eighth leading cause of death in America. This report made healthcare take a hard look at RCA.

Key Facts

• At 15 years old, healthcare RCA is considered young. Most other industries/communities that use RCA
have been using them since the 1950's after Sakichi Toyoda used the 5 whys causal analysis technique to
streamline his production process.

• An RCA can either be Proactive or Reactive.

◦ Proactive RCA is meant to catch problems before the product or process is released.

◦ Reactive RCA is used to determine what happened after an incident occurs.

◦ The output of an Reactive RCA investigation can become the input to a Proactive RCA.

• Healthcare is unique in that it has a greater need for Reactive RCA than any other industry. The reactive
nature of healthcare leads to sentential events. These numbers are provided by the Bureau of Labor
Statistics and do not contain death totals.

Education and health services .......................... 2009 2010 2011
Goods producing................................................ 5.0 4.8 4.7
Manufacturing ................................................... 4.3 4.2 4.2
Natural resources and mining............................ 4.3 4.4 4.4
Construction ...................................................... 4.0 3.7 4.0
Trade, transportation, and utilities...................... 4.3 4.0 3.9
Leisure and hospitality ...................................... 4.1 4.1 3.9
Private................................................................ 3.9 3.9 4.0
Service providing ............................................... 3.6 3.5 3.5
Other services, except public administration ..... 3.4 3.4 3.3
Information ......................................................... 2.9 2.7 2.6
Professional and business services ................... 1.9 1.8 1.6
Financial activities .............................................. 1.8 1.7 1.7
1.5 1.3 1.4

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Current Investigation Techniques

The process of investigating a Reactive RCA in the healthcare community is completed using a diverse set of
programs including MS Word, MS Excel, MS PowerPoint, MS Visio and any number of other support systems.
Communication, organization and sharing of knowledge can be difficult.

Manual Investigation Task Process Analysis
In this section we will look at a common implementation of a Root Cause investigation.

Task Tool Process Issues/Problems

Take Notes and Collect Microsoft Word -Use Word to create the status report. -Requires extensive manipulation of Excel to insert
Evidence Microsoft Excel -Use Excel to record the events. events as they are discovered.
-Template reports are used and sometimes the files
Create a Sequence of Events are misplaced.

Determine the Unsafe Acts, Microsoft Visio -Use the notes and collected evidence -Manipulation of Visio to insert and move events
influences and Root Causes and build a flow of events. around is tedious.
-Adding an event to the middle of the Visio chart
Create an Action Plan -Use Visio to build a flow of events in a can cause the need to redistribute event boxes
linear format. between pages.
Report the Findings for
Management Review Microsoft Visio -Add conditions and root causes to the -Manipulation of Visio to add influence boxes is
Implement the Action Plan Visio event sequence. tedious
-Splitting the influence path is tedious.
-Creating the lines to link the events and influence
is difficult.

Microsoft Word -Use Word to create status report. -Manipulating the Excel sheet and redistributing the

Microsoft Excel -Use Excel to layout an Action Plan. plan is tedious

-Action plan is created as a matrix of -Communication with the team is difficult.

risk reductions and measures.

-Reports and Action Plan are created in

Word and sent to all team members by

email.

Microsoft Word Use Word to create a report on the root -Preparation of the report is tedious as all other
causes and possible Risk Reductions documentation needs to be incorporated.

Microsoft Word -Use Word to create reports -Manipulation of the Excel spread sheet is tedious.

Microsoft Excel -Modify the Action Plan as the needed -Communication through email is difficult

changes are discovered.

-Redistribute plan to all team members.

Report the Findings Microsoft Word -Use Word to create Spread Plan and -Manipulating Power Point to create the Cheese
Microsoft Excel Lessons Learned.
Review the Results Model is tedious.
Schedule Investigation Tasks Microsoft -Use Power Point to create the Cheese -Communication with team and upper management

Power Point Model. is difficult.

-Use Excel to distribute the results of -Template reports are used and sometimes the files
the implementation.
are misplaced.
-Distribute the reports to team

members and upper management

Microsoft Word -Never Happens – Use the reports from -Usually too busy to do the review.

Microsoft Excel the implementation and the Excel -No way to know when the review is due.

spread sheet.

Microsoft Word Handled through the email system -difficult to maintain multiple teams using mail
Microsoft Excel system

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Data Collection

There are several challenges to undertaking root cause analysis in health care. These are associated with forming
and leading the investigation team; gathering and analyzing supporting evidence; and formulating and implementing
service improvements. Undertaking root cause analysis remains a complex non-linear task which entails balancing a
multiplicity of concerns and expectations. Supporting enhanced incident investigation requires keeping in focus the
instrumental aim of triggering sustainable service improvement and not for the investigation to become an end in itself.

http://www.ncbi.nlm.nih.gov/pubmed/21460348

• Collection of data utilized for Root Cause Analysis
a. Investigation report
b. Autopsy report
c. Police reports
d. Interviews
e. Consumer record (including medical record)
f. Incident reports
g. Staff notes/log
h. Photographs or physical materials involved in the incident
i. Pertinent policies, procedures, protocols, and guidelines
j. Training records
k. Staffing schedules
l. Inspection or quality review records
m. Program/site description
n. Sequence analysis and associated flowchart(s) prepared by knowledgeable staff that
summarize exactly what happened in chronological order.

In a manual process, all this data is collected by hand and stored in excel, word or in file or
desk drawers.

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Manual Issues
• Heavy Manual Process - Investigation process is heavy with many manual processes such as building spread
sheets,reports, diagrams and contacting team members.
• MS Office Suite - The use of the Microsoft Office suite of products is ineffective and burdensome on most
large investigations.
• User Knowledge of Products - The user must have a basic to good working knowledge of Word, Excel,
Power Point and Visio. The typical investigator is a nurse that has moved out of patient care and into patient
safety. Advanced medical knowledge is needed to perform the investigation. Most people typically do not
have more than a basic understanding of each of these products.
• Visio is a Key Problem - The larger the Visio diagram gets the more burdensome it becomes to handle and
the more likely it is for investigators to overlook some important details.
• No Standardization - No standardized plan for storing and archiving the incidents and results. These
practices vary from site to site. Image evidence is stored anywhere from a local drive to a system server.
• Hard Communication – Contacting team members and keeping the team on the same page is difficult.
Sometimes computer access is limited or team members are left out of the email list.
• Security – this data is very sensitive and many times the basis to a malpractice suit. It is not adequately
stored and secured.

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RootModel Solutions Design Goals.
• Integrated System - Provide an integrated system that supports all phases of the investigation process,
increases communication between team members and provides a greater level of security for the data.
Removes the need for all MS Office products.
• Mimic the MS Products – Since the user community is familiar with MS office products, RootModel will strive
to mimic the look and feel of each tool used in the investigation process. This should decrease the learning
time for the average user.
◦ An Excel Grid like tool will be used to collect the notes
◦ A Visio like tool will be used to perform event sequencing and causal influences.
• Dashboard – Provide a page to let the user know the status of all open investigations, new help requests and
progress reports.
• Eliminate PowerPoint – This product is used to create the Cheese Model Report and is difficult to manipulate.
RootModel will be able to create this report automatically and eliminate the need for PowerPoint.
• Enable Team Communication – The email address of each team member will be kept in the database and
any correspondence can be sent to the entire team or team individuals.
• Provide Integrated Training – Training videos and documents and The Training Coach for help in
understanding the investigation process and clues when performing an investigation.
• Secure Report Display – Use PDF in a secured directory with a secure link sent by email to allow team
members and upper management access to reports.
• Support Implementation – During the implementation process, provide a sub-system for help requests,
progress reports and score cards for understanding how effective the risk reductions have been.
• Team Implementation Page – The team implementing the changes, needs to logon and submit help requests,
progress reports and enter score card values. RootModel needs to provide a sub-system for these users.
• Print and Save As – Provide the ability to print all reports or save the report as a PDF.
• WSYWIG – All reports should be 'what you see is what you get'. This should provide a further level of user
familiarity and comfort.
• Reporting – Provide a Status Report, Lessons Learned, Spread Plan and Cheese Model report.

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Healthcare Statistics

• 60,000 Incidents in Medium to Large Hospital.
Not all cause harm to the patient
Multiply this figure by all 5000
http://community.the-hospitalist.org/2009/09/20/hospital-incident-reporting-systems-time-to-slay-the-monster/

• 400,000 deaths a year
Medical errors leading to patient death are much higher than previously thought, and may be as high
as, according to a new study in the Journal of Patient Safety.

• Third leading cause of death behind heart disease

The new study reveals that each year preventable adverse events (PAEs) lead to the death of 210,000-

400,000 patients who seek care at a hospital. Those figures would make medical errors the third leading

cause of death behind heart disease and cancer, according to Centers for Disease Control and

Prevention statistics.

http://www.fiercehealthcare.com/story/hospital-medical-errors-third-leading-cause-death- dispute-to-err-

is-human-report/2013-09-20

• As Many as 114,000 Adverse Events a Day World Wide

A new study in BMJ Quality & Safety finds that nearly 43 million adverse events occur during the 421 million

hospitalizations across the globe each year, and those events have a major impact on the lives of

patients.

http://www.advisory.com/daily-briefing/2013/09/20/adverse-events-occur-in-hospitals-each-day

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