Cathleen Rohling is chief operating officer for AAAHC-accredited GastroIntestinal Associates Endoscopy Center in Wausau, Wis. She discusses a few recent efforts her two-year-old center has undertaken to better meet accreditation standards concerning risk management and root cause analysis.
Q: You recently developed and implemented a risk management committee. Why did you do this and who is in this committee?
Cathleen Rohling: We implemented the risk management committee to enhance coordination of risk management, infection control, safety and corporate compliance programs. It was a direct outcome from our one-year recertification visit. The recommendation from our surveyors was to take a good hard look at how we were handling risk management. We had the pieces but not the structure to coordinate it, partially because we have a small shop. This committee includes our safety officer, infection control officer, who is also our endocenter director, our corporate compliance officer, who is also fiscal director, the person who handles the competencies for our staff and HR assistant.
Q: What are some of the projects undertaken by this committee?
CR: We have a calendar where we're tracking all of the training such as ACLS courses and BLS training. We're putting out our competency training at least a quarter in advance — what week is going to be tech training, what week is going to be nursing training, etc. All of our drills are on the schedule for a year in advance. We've worked to project out a year to a year and a half. We brought in the American Society for Healthcare Risk Management materials and we reviewed the profiles of good risk management programs. We then used that same material and looked at incident reporting and how ASHRM prefers that you think about incident reporting.
Q: What have you done to enhance your knowledge and implementation of a root cause analysis process?
CR: We were made aware of the resource called ThinkReliability.com. We've been struggling as a small shop with all of the obligations that large shops have on how to efficiently put into place QI and root cause analysis because in large places they have experts who are credentialed and trained in that and it's all they do. Here we need to learn how to do it and be good at it but with the resource we have.
ThinkReliability has videos about how to think about root cause analysis and they offer many free videos on their website. The one thing that drives me crazy about QI is the language surrounding it keeps changing. This firm specializes in simplifying and demystifying it. This website is about evaluating incidences and occurrences in light of your processes and people and identifying opportunities to avoid it in the future. We're going to pretty much base the rest of our program from this point forward on their models.
Learn more about GastroIntestinal Associates Endoscopy Center.
Visit ThinkReliability.com.
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- 3 Ways a Young GI ASC Reduced Costs
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