Quality and Safety Tools

AONE has identified the following tools on quality and safety to assist you in preventing and analyzing health care-related adverse events and close calls.
To ensure you are viewing the most up-to-date information on any of the web-based resources, you may want to start at the home page and then progress to the pages with quality and safety content.
Please forward suggestions for additional resources to Janet Stifter. Commercial web sites and products other than patient safety books and publications will not be considered for inclusion.

Tools links
Cause and Effect Diagram
Failure Modes and Effects Analysis (FMEA)
Root Cause Analysis
Safety Incident Analysis
General Performance Improvement

Cause and Effect Diagram (Ishikawa or “fishbone” diagram)

Cause and Effect Diagram
Source: Institute for Healthcare Improvement
Description: The cause and effect diagram, also known as an Ishikawa or "fishbone" diagram, is a graphic tool used to explore and display the possible causes of a certain effect. Use the classic fishbone diagram when causes group naturally under the categories of Materials, Methods, Equipment, Environment, and People. Use a process-type cause and effect diagram to show causes of problems at each step in the process.

Fishbone (Ishikawa) Diagram 
Source: American Society for Quality
Description: This resource provides an overview of the fishbone diagram method, procedure, example, and Excel tool for getting started.

Failure Modes and Effects Analysis (FMEA)

Failure Modes and Effects Analysis Tool
Source: Institute for Healthcare Improvement
Description: Teams use the interactive FMEA Tool to evaluate processes for possible failures and to prevent them by correcting the processes proactively rather than reacting after failures have occurred. The FMEA Tool is particularly useful in evaluating a new process prior to implementation and in assessing the impact of a proposed change to an existing process.

 

Failure Mode and Effects Analysis: A Tool to Help Guide Error Prevention Efforts
Source: Institute for Safe Medication Practices
Description: This resource provides a step-by-step example of how FMEA could be used to reduce the risk of medication errors. A complete sample is also provided of a FMEA for IV Patient Controlled Analgesia.

Healthcare Failure Mode and Effect Analysis
Source: VA National Center for Patient Safety
Description: The Healthcare Failure Mode and Effect Analysis (HFMEA) has been designed by the VA National Center for Patient Safety (NCPS) specifically for healthcare. HFMEA streamlines the hazard analysis steps found in the traditional Failure Mode and Effect Analysis (FMEA) process by combining the detectability and criticality steps of the traditional FMEA into an algorithm presented as a Decision Tree. It also replaces calculation of the risk priority number (RPN) with a hazard score that is read directly from the Hazard Matrix Table.

Root Cause Analysis

Root Cause and Systems Analysis Web-based Training Course
Source: Institute for Healthcare Improvement
Description: This course introduces students to a systematic response to error called root cause analysis (RCA). The goal of RCA is to learn from adverse events and prevent them from happening in the future. The three lessons in this course explain RCA in detail, using case studies and examples from both industry and health care. By the end, you’ll learn a step-by-step approach to completing an RCA after an error – and improving the process that led to the error.

Framework for Conducting a Root Cause Analysis and Action Plan
Source: The Joint Commission
Description: The Joint Commission Root Cause Analysis and Action Plan tool has 24 analysis questions. The framework is intended to provide a template for answering the analysis questions and aid organizing the steps in a root cause analysis. 

 

Root Cause Analysis Toolkit
Source: Minnesota Department of Health
Description: The Root Cause Analysis Toolkit contains sample policies, position descriptions and agendas, graphic organizers and visual aids, question guides, invitations and ground rules, case studies and other documents that facilities can use to educate their staff, their RCA facilitators, or their leaders about this process.

Safety Incident Analysis

Systems Analysis of Clinical Incidents: The London Protocol
Source: Clinical Safety Research Unit, Imperial College London
Description: The London Protocol outlines a process of incident investigation and analysis developed in a research context, which was adapted for practical use by risk managers and others trained in incident investigation. This revised approach has now been refined and developed in the light of experience and research into incident investigation both within and outside health care.

 

Clinical Incident Management Toolkit
Source: Government of Western Australia Department of Health
Description: The Clinical Incident Management Toolkit aims to provide practical advice and resources for clinicians and managers to understand, undertake and utilize health data to improve the safety and quality of health care delivery.

Incident Analysis Framework
Source: Canadian Patient Safety Institute
Description: The Incident Analysis Framework is a is a resource to support those responsible for, or involved in, managing, analyzing and/or learning from patient safety incidents in any healthcare setting with the goal of increasing the effectiveness of analysis in enhancing the safety and quality of patient care.

Incident Management Tools 
Source: Canadian Patient Safety Institute
Description: The website contains links to tools selected from publicly available documents and are grouped around the main steps of the incident management continuum: before the incident, immediate response, preparing for analysis, analysis process, follow-through, and closing the loop.

General Performance Improvement

Performance Improvement Plan and Template
Source: Health Care Association of New Jersey
Description: This guide is a planning template for health care professionals working with long-term care patients to improve and sustain performance improvement strategies. The template can be customized through forms and analytical tools to apply in settings such as nursing and skilled nursing facilities, subacute care facilities, assisted living facilities and programs, residential care settings, and adult medical day health care services.