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About this IHI Virtual Expedition

​Root cause analysis (RCA) is a process widely used by health professionals to learn how and why errors occur. While RCA has been part of health care and patient safety for more than 15 years, success has been variable both within and across institutions.

This Institute for Healthcare Improvement (IHI) Virtual Expedition will explore the process of Root Cause Analyses and Actions (RCA2). Expanding on RCA, RCA2 is  used to drive improvement when it comes to reviewing events that cause or may cause serious harm, and in developing and implementing sustainable and measurable actions that prevent future harm to both patients and staff.

What You'll Learn

At the end of this Virtual Expedition, participants will be able to:

  • Identify the current state of root cause analysis (RCA), and why improvements are essential
  • Describe the methodology and processes associated with RCA2
  • Utilize tools that are used in the RCA2 process
  • List approaches for evaluating the success of RCA2


The continuing education credits for this IHI Virtual Expedition are currently being finalized.

Schedule

Session 1: Understanding RCA2: The Process of Event Review
Date: Wednesday, January 24, 2018, 12:00 PM–1:00 PM ET

Session 2: Identifying and Classifying Events for Review
Date: Wednesday, February 7, 2018, 12:00 PM–1:00 PM ET

Session 3: Event Review: Determining the Team and Engaging the Patient
Date: Wednesday, February 21, 2018, 12:00 PM–1:00 PM ET

Session 4: Event Review: Finding and Mapping the Facts
Date: Wednesday, March 7, 2018, 12:00 PM–1:00 PM ET

Session 5: Event Review: Determining the Cause and Effective Actions
Date: Wednesday, March 21, 2018, 12:00 PM–1:00 PM ET

Session 6: Implementation, Measurement, and Feedback
Date: Wednesday, April 4, 2018, 12:00 PM–1:00 PM ET

Faculty


Rollin J (Terry) FairbanksRollin J. (Terry) Fairbanks, MD, MS, FACEP, CPPS is Associate Director of the MedStar Institute for Innovation (MI2), where he is responsible for the National Center for Human Factors in Healthcare and the Simulation Training & Education Laboratory (MedStar SiTEL). Dr. Fairbanks also serves as an attending physician in the emergency department at MedStar Washington Hospital Center. In addition, he is an Associate Professor of Emergency Medicine at Georgetown University and maintains an academic appointment as Adjunct Associate Professor of Industrial and Systems Engineering at the University at Buffalo. Dr. Fairbanks's unique background in human factors and industrial systems engineering, along with his experience as a board-certified emergency physician and a former paramedic and EMS medical director, enables him to apply safety engineering techniques and research methodologies to medical systems. Dr. Fairbanks was a member of the core working group that developed RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.

James Bagian James P. Bagian, MD, PE, Director for Healthcare Engineering and Patient Safety, University of Michigan is focused on creating solutions that will make healthcare safer, more effective, and efficient for patients. Dr. Bagian’s primary interest and expertise are in the development and implementation of multidisciplinary programs and projects that involve the integration of engineering, medical/life sciences, and human factor disciplines. He is applying the majority of his attention to the application of systems engineering approaches to the analysis of medical adverse events, and the development and implementation of suitable corrective actions that will enhance patient safety primarily through preventive means. Dr. Bagian directs the Center for Healthcare Engineering and Patient Safety (CHEPS), and he is an elected member of the National Academy of Medicine and the National Academy of Engineering. Previously, he served as the first chief patient safety officer and founding director of the National Center for Patient Safety (NCPS) at the U.S. Department of Veterans Affairs (VA). Dr. Bagian was a member of the core working group that developed RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.

Katherine Kellogg Kathryn M. Kellogg, MD, MPH, is a researcher and patient safety professional with significant experience applying human factors principals to patient safety issues. As the Associate Medical Director, she provides clinical expertise for grants and contracts at the National Center for Human Factors in Healthcare. She also directs the human factors event reviews and hazard analyses, and serves as a liaison between the Human Factors Center and the MedStar Safety team, integrating safety science into innovative safety interventions implemented across the system. Dr. Kellogg also conducts research on patient safety issues, and is currently the principal investigator for the Center’s pilot test of the Agency for Healthcare Research and Quality’s Quality and Safety Review System. Dr. Kellogg’s research interests include adverse event review, a topic on which she has published original research, and physician stress and burnout. She studied medicine at the University of Rochester School of Medicine and Dentistry, and earned her Master in Public Health from The Dartmouth Institute, with a focus in systems approach to healthcare improvement. She completed her residency in Emergency Medicine at Vanderbilt University. Dr. Kellogg’s work has been supported by the Agency for Healthcare Research and Quality (AHRQ) and the MedStar Health Research Institute. Dr. Kellogg is also a board-certified Emergency Medicine Physician who practices and teaches at MedStar Washington Hospital Center, and is an Assistant Professor of Emergency Medicine at Georgetown University.

Setj Krevat Seth A. Krevat, MD, FACP, is the Assistant Vice President of Safety at MedStar Health, an Assistant Professor of Clinical Medicine at Georgetown University School of Medicine, and an Attending Physician of Palliative Medicine at MedStar Georgetown University Hospital. Dr. Krevat was recruited to MedStar Health to lead the development of their comprehensive safety program. He is responsible and accountable for all patient safety and risk reduction programs across MedStar Health. Under his guidance, MedStar has experienced massive culture change: implemented the tools and behaviors of a High Reliability Organization, implemented a new event review process to evaluate serious safety events through the lens of safety science, and leveraged the value of increasing numbers of incident reports submitted by MedStar’s workforce. Dr. Krevat received a Bachelor’s Degree in economics and English from Tufts University and a Medical Doctorate from Georgetown University School of Medicine.