Root Cause Analysis to Improve Incident Reporting in an Ambulatory Care Setting

Problem: The subject organization (SO) is a Federally Qualified Health Center (FQHC) with an internally developed incident reporting system. The SO wanted to improve patient and employee safety using data from incident reports, but the incident reporting system did not give enough information to recognize patterns and develop countermeasures. Context: Supervisors welcomed the opportunity to learn more about incident report follow-up and conducting root cause analysis (RCA). Members of the Safety Committee were eager for data to use to develop countermeasures to improve patient and employee safety. Decreases in employee injuries can save the SO from increases in the cost of worker’s compensation coverage, so the SO leadership supported the project. The organization is covered by the Federal Tort Claims Act (FTCA) for malpractice insurance, but there is always a cost to preparing a defense against claims, so the Chief Financial Officer was supportive of a project that could reduce the chance of claims. Interventions: The project was conducted in three stages. The first stage was to design a data collection tool for supervisors to use to guide incident report follow-up and document RCA. The second stage was to conduct training sessions for supervisors to teach them about organizational fairness, using a human-factors approach to evaluate incidents, how to conduct an investigation, and how to perform RCA. The third step was to send the data collection tool to supervisors to collect additional information about incidents. The data were extracted from the completed tools and presented to the Safety Committee. Measures: The project measured effectiveness of the class in increasing confidence with doing RCA and conducting IR follow-up. The project also measured the effectiveness of the class in training supervisors to use the data collection tool correctly. A third measure was whether the training and use of the tool improved the rate of RCA documentation in IRs when it was assigned to supervisors. Results: The emphasis of the class training shifted due to the need to do remedial incident report training with the supervisors, therefore completion of the data collection tool was de-emphasized. Of the returned responses, most (95.7% for general incident and 98.4% for employee incident) respondents completed the section requesting an analysis of accident causes. Just over half of the respondents (54.3% and 51.6%) completed the analysis of workflow variance, and few (17.4% and 20.3%) provided a root cause. The comfort level with collecting additional information after an incident increased 24.9% and the agreement with understanding how to conduct RCA increased 46.5%. The completion rate of RCA documented in the IRs themselves increased slightly from 61.5% in the 24-week period before the intervention to 67.9% in 24-week intervention period. Conclusions: While the project has not yet provided a direct benefit to the SO by producing countermeasures for incidents, the work done by the project lead and the Senior Vice President and General Counsel (SVPGC) will enable the SO to improve the incident reporting system. The project implies that more training is needed for supervisors to conduct follow-up investigations and to do RCA after an incident. The findings also imply that the organization needs to spread a culture of safety to all departments and to all levels. In addition to improving patient care by decreasing errors, establishing a culture of organizational fairness and safety may support other quality improvement efforts and help with employee retention

An Analysis of Effective Practice Strategies for the Performing Undergraduate University-Level Pianist

The intent of this study was to provide awareness of the trends surrounding piano practice pedagogy as determined by students either immersed in a university piano program or graduates thereof. The areas of study include a historical context of university music programs and the field of piano pedagogy, trends of imitative instruction, the importance of qualitative and quantitative practice, and the discovery of piano practice routines of collegiate pianists. This research project was approved for an IRB exemption by the Old Dominion University College of Arts and Letters. Within this study, the subjects were either graduates of a collegiate piano department or students in a public four-year university music program, private four-year university music program, community college music program, or music conservatory music program (N = 160). The subjects completed a survey within Qualtrics that contained an informed consent statement. The survey was limited to subjects in the United States. The subjects answered questions about their specific involvement in collegiate piano studies and discussed individual practice habits regarding levels of practice efficiency, daily time spent practicing, motivating factors for individual practice, extramusical factors that affect daily practice, specific practice strategies taught by their private teachers, and practice methods employed without instruction. The data were analyzed using the Qualtrics survey application. The results from the survey highlight the need from applied piano teachers to provide more specific instructions regarding practice techniques

Shrink your Sierra System

Although our Sierra system runs well, periodic maintenance helps us recognize trends that determine when to grow and when to shrink our system. Changes on campus and in our community indicated it was time to closely examine our coding structure and do some cleanup. This presentation discusses ways to find and safely remove outdated patron types, item types, and other codes

Search Scoping

Search scoping allows you to create subsets of your database, and determine which records belong in each scope. Although scoping can also be applied to staff activities, this poster is concerned with scoping as applied to the web catalog

Motherhood, Faith, Feminism and the Legacy of the 2008 U.S. Presidential Election

The unprecedented participation of female candidates in the 2008 presidential election received considerable media attention and occasioned often virulent public debate about the current status of women in American politics and the state of feminismin the country as a whole. Underlying this debate were evolving paradigms of motherhood, faith and feminism. Exploring the media’s portrayal of Hillary Clinton, Sarah Palin and Michelle Obama, this article examines the role of this election in eliciting debates about motherhood, the role of women in the political realm, the definition of feminism and the role of religion in political discourse. Such an exploration reveals failures of modern articulations of feminism to appeal broadly to the electorate generally and American women in particular and partially explains the failure of both parties to advance a successful female candidate. These failures suggest that as women increasingly desire and expect to see themselves reflected in the political landscape, paradigms of feminism must expand to include traditional family constructs, conservatism, faith and the complexity of life today

Perceptions of High School Graduates and High School Dropouts Regarding Early Education Experiences

The purpose of this study was to analyze the perceptions of high school graduates and high school dropouts regarding early childhood education. Research shows that dropping out of high school can have negative societal, economic, and emotional impacts. Waiting until a student reaches high school to provide support that may prevent the student from dropping out can have adverse consequences. Children form cognitive, affective, and physical skills and abilities during their first 5 years of life. Known as the formative years, how a child’s learning is supported and enhanced during the first 5 years can be essential for school readiness and success. To explore the relationship of high school dropouts and graduates regarding their early learning experiences and their perceptions of early childhood education, this dissertation analyzed the impacts of early education on a student’s high school success. Data were collected through a survey instrument and focus-group interviews for qualitative and quantitative results. Participants in Sample Group 1 were high school dropouts enrolled in an adult high school program at a rural community college in North Carolina. Sample Group 2 participants were high school graduates enrolled in an AAS degree-seeking program at the community college. Per analysis of the data, it was determined that early learning experiences that occur after age 1 as well as the type of supportive relationship a teacher establishes with students can determine a student’s ability to become a high school graduate. In addition, the results indicated that while high school graduates felt that interpersonal skills such as working well with others and following procedures were instrumental in preparing children for school, data indicated that high school dropouts perceived rote skills such as counting and knowing shapes and colors as having the greatest influence on a child’s preparedness for school

Teaching responsible suicide reporting (RSR) : using storytelling as a pedagogy to advance media reporting of suicide

Reporting suicide is an important but challenging area of journalism practice. Learning how to report this complex, distressing subject is vital for journalists if they are to avoid contributing to the 800,000 annual suicidal deaths worldwide (WHO, 2019). Tuition on suicide reporting in higher education tends to be didactic and theoretical, focussing on media guidelines and codes of conduct. Thereafter, journalists’ ability to implement this guidance is mixed. To address this, the authors devised the Responsible Suicide Reporting Model (RSR) which is grounded in news-work and embeds media guidelines within journalistic storytelling, consisting of a typology of suicide narratives and 'othering', ethical rules and a standard of moderation. This study tests the effectiveness of teaching the RSR Model using storytelling-as-pedagogy and problem-based learning. Firstly, we investigated students' perspectives on current educational offerings on suicide reporting through a survey of 229 students in the UK and Ireland who had no exposure to the RSR model. We then ran workshops with 80 students in the UK, teaching them the RSR model. The results showed that students with no exposure to the model–while they seemed to be aware of the theory of responsible suicide reporting–did not know how to implement it. Students who participated in workshops, where the RSR model was used, reported a greater understanding of responsible suicide reporting, believing they became better critically reflective practitioners

Database Maintenance from the Central Catalog to Your Local System

As we start to anticipate next year\u27s ILS Migration, one thing is certain: Clean data will make the migration easier--at the local and consortium levels. This presentation will provide ideas and resources to help institutions start or accelerate database and system maintenance in preparation for migration. Erin Kilkenny will discuss OhioLINK\u27s database maintenance projects in the Central Catalog and highlight resources available via Ostaff. Leigh Duncan will share ideas for streamlining codes and data within your Sierra system