Root Cause Analysis: Advanced Principles and Practices

Enhance your root-cause analysis (RCA) skills with Root-Cause Analysis: Advanced Principles and Practices, ECRI and the Institute for Safe Medication Practices PSO’s virtual RCA training. During this half-day live virtual training, RCA experts will cover advanced concepts, techniques, and strategies that will help participants improve their existing RCA process. Key concepts include just culture model, investigative interviewing, communication of safety events to patients and families, and strategies to operationalize and implement RCA improvement actions.

This training is an interactive learning opportunity that blends didactic presentations by subject matter experts and group case study reviews and exercises.

Learning objectives

At the conclusion of the training, participants will be able to:

• Understand how a just culture approach can improve the culture of safety around patient safety event reporting.
• Discuss techniques to improve investigative interviewing during the RCA process.
• Understand how to use human factors and system design principles to strengthen action planning.
• Discuss opportunities to identify health disparities and inequities through the RCA process.
• Describe strategies to effectively communicate with patients and families when a patient safety event has occurred.

Event details

• When: October 26, 2023 from 12:00 p.m. - 5:00 p.m. ET
• Where: Link to virtual platform will be provided upon registration
• Cost: $995 USD per person
• Who should attend: risk managers, quality and performance improvement professionals, patient safety officers
• Competency level: proficient to expert

Space is limited for this event.

Agenda:

• 12:00 – 12:15 p.m. ET – Overview and Background
• 12:15 – 1:15 p.m. ET - Session I: Just Culture: Balance of Accountability and Safety
• 1:15 – 1:30 p.m. ET - Case Study Discussion: Just Culture
• 1:30 – 2:15 p.m. ET - Session II: Interviewing: Essential Skills for Conducting Investigative Interview
• 2:15 – 2:30 p.m. ET - Case Study Discussion: Investigative Interviewing
• 2:30 – 2:45 p.m. ET – Break
• 2:45 – 3:45 p.m. ET - Session III: Strategies to Operationalize and Implement Strong RCA Actions
• 3:45 – 4:00 p.m. ET - Case Study Discussion: Action Planning
• 4:00 – 4:45 p.m. ET - Session IV: Communicating Events: Sharing with Patients and Families

Speakers:

Shannon Davila MSN, RN, CPPS, CIC, CPHQ, FAPIC

Director Total Systems Safety, ECRI

With a clinical background in adult critical care nursing, Shannon specializes in infection prevention and healthcare quality improvement. Shannon has provided leadership throughout several state and national patient safety programs, including the New Jersey Sepsis Learning Action Collaborative and CMS Hospital Improvement Innovation Network. Shannon has co-led both the national CMS Sepsis and Antimicrobial Stewardship Affinity Groups. She has authored a book and published several articles that focus on the importance of infection prevention. In 2016, Shannon was honored with the Association of Professionals in Infection Control and Epidemiology (APIC) Heroes of Infection Prevention Award. She has served as APIC Northern New Jersey Chapter President and Chapter Legislative Representative. Shannon is certified in infection control, healthcare quality, as a TeamSTEPPS Master Trainer and High Reliability coach. She received her BSN from the University of Southern Maine, her MSN from Walden University, and in 2020 was inducted into the APIC Fellow program.

Mary C. Magee, MSN, RN, CPHQ, CPPS

Senior Patient Safety / Quality Analyst and Consultant, ECRI

In her role with ECRI and the Institute for Safe Medication Practices PSO, Mary provides liaison services for member organizations, reviews and analyzes adverse event reports, and uses the information to develop written material, continuing education programs, webinars, and presentations to educate healthcare facilities about regulatory, quality improvement, and patient safety issues. Before joining ECRI, she was Senior Director of Quality, Regulatory Affairs, and Patient Safety for a large multihospital health system. She has extensive experience leading multiple successful routine and for-cause CMS, Department of Health, and Joint Commission surveys; instituted and maintained accreditation and regulatory preparedness; and conceived and lead the successful implementation of the strategic direction for quality, safety, and performance improvement.

Matthew Grissinger, RPh, FISMP, FASCP

Director, Error Reporting Programs, ISMP

Matthew’s responsibilities include working with healthcare practitioners and institutions to provide education, using high-reliability concepts in identifying risk and preventing medication errors, and review medication errors that practitioners have voluntarily submitted to a national ISMP Medication Errors Reporting Program. He also served as a home care and long-term care pharmacy surveyor for the Joint Commission. Matthew is a frequent speaker on pharmacy topics and current issues in medication safety. He has published numerous articles in the pharmacy literature, as well as being a chapter contributor to a textbook published by McGraw-Hill. Matthew is the chair of the National Coordinating Council for Medication Error Reporting and Prevention and co-chair of the National Quality Forum Common Formats Expert Panel. He served on the U.S. Pharmacopeia’s Safe Medication Use Expert Committee, the FDA Proprietary Name Review Concept Paper workshop panel, Editorial Board for P&T, and the Naming, Labeling, and Packaging Practices to Minimize Medication Errors workshop panel.

Jeraldine S. Stoltzfus, MBA-HA, RN, BA

Manager, Patient Safety Organization & Safety Solutions

Jeraldine is experienced in nursing, care management, quality improvement, risk management, and patient safety. Most recently, she became the manager of ECRI’s Patient Safety Organization (PSO), leading ECRI’s team of Patient Safety Analysts responsible for conducting risk-cause analysis educational presentations, deep-dive event analysis and trends, and process improvement and liaison services for member organizations.

Her roles in risk management and patient safety in large acute care facilities and ambulatory care centers have given her the skills necessary for efficient and effective project management, team facilitation, and the ability to implement surveys and event investigations, including root-cause analysis. Her experiences have engaged a culture of safety for patients and staff.

Her goal is to collaborate and build a strong sustainable approach to healthcare safety improvement.

Chris Barfield, MHIT, RN, CPPS

Patient Safety Analyst

Chris joined ECRI in 2022 as a Patient Safety Analyst. He is a registered nurse (RN) who has worked mainly in the developmental disabilities and aging services sectors. He holds degrees in public health and health information technology, both from the University of South Carolina, and has extensive experience in healthcare data analytics, process improvement, and project and change management. His goal is to provide insight and tools that assist and inspire individuals to drive change at their organizations to ultimately make lasting impacts on their patient populations. He is Master Certified in Just Culture.