Every so often I get to interview someone who applies quality methodology in ways I wouldn't have imagined before I began working at Minitab. For instance, I spoke with the quality manager for a world-renowned medical center not long ago. This facility is consistently included in U.S. News and World Report's list of America’s Best Hospitals, but even the best hospitals occasionally have “sentinel events,” incidents that result in death or serious injury unrelated to the natural course of a patient’s illness.
Health care providers are required to determine what went wrong in a sentinel event and develop a plan to keep it from happening again.
This investigation, called a Root Cause Analysis (RCA), can be extremely complicated. The RCA is conducted by a multidisciplinary team comprising members of the affected departments. The team explores and analyzes all potential causes of the event, identifies risk reduction strategies, then implements a correction plan. “The RCA helps us carefully analyze and understand precisely what happened, and learn how how to avoid similar events in the future,” the hospital's quality manager told me. “Doing it right is critical to helping us ensure patient safety.”
But when the hospital began doing RCAs, existing tools made a difficult task even more challenging. “The analysis includes a host of complicated steps, and the tools we were using couldn’t handle all the things we needed to do,” the quality manager said.
That brought us to the reason for our interview: I wanted to find out how this hospital was using Companion by Minitab, our process improvement software. They didn't get Quality Companion specifically to perform Root Cause Analyses, but it turns out the software was well suited to the task.