11 Organizational Use of TERCAP®
Shifting From a Quality Management to a Whole-Systems Approach
Serious quality problems continue to exist in the health care industry in spite of a highly trained workforce of skilled and motivated people who are technically proficient (Chassin & Galvin, 1998). A fundamental shift in thinking is required to create safe and reliable practice environments for technically proficient practitioners. This shift begins with the recognition that a quality management approach is not enough, and that a whole-systems management approach is required.
SENTINEL EVENTS AND THE PATIENT SAFETY MOVEMENT
Sentinel events are any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. The phrase or the risk thereof includes any process variation for which a recurrence would carry a significant chance of a serious, adverse outcome. The events are called sentinel because they signal the need for immediate investigation and response (Speelman, 2001). In 1998, The Joint Commission on the Accreditation of Healthcare Organizations implemented standards and recommendations related to identifying, reporting, analyzing, and presenting sentinel events that had become more commonly reported in health care organizations throughout the country. These recommendations, however, fell short of expectations, and these unfulfilled expectations provided a segue to the patient safety movement.
The patient safety movement, while clearly visible, is still in its infancy. Many hospitals continue to punish care providers for the errors they make, and regulatory bodies are seen as searching for villains and punishing those who get caught. Meanwhile, the focus of many health care leaders has been on acquisitions, mergers, reimbursement, and revenue, rather than on the core focus of patient care. The patient safety movement will not progress until health care leaders move away from traditional models of management that focus almost exclusively on the bottom line to a multidimensional approach that focuses on other dimensions of organizational fitness—that is, the normative, strategic, and operational aspects of the organization (Schwaninger, 2000).
ORGANIZATIONAL USE OF TERCAP®
The Practice Breakdown Advisory Panel (PBAP) developed and used the Taxonomy of Error, Root Cause Analysis and Practice Responsibility (TERCAP) audit (introduced in Chapter 1) as one method in a study of practice breakdown in multiple health care settings. The goal of this research (Scott, 2004) was to study selected error-events and identify the multiple individual, team, system, and cultural contributors to the practice breakdown that resulted in harm to a patient. It was asserted that an enhanced analysis would result within the context of a comprehensive framework by incorporating TERCAP into the root cause analysis and investigative process. Data collection included systematic root cause analysis findings and data obtained from medical records, staffing schedules, and physician and employee interviews. TERCAP proved to be a very useful data collection instrument for organizing and analyzing the data.