Shine a Light on Stigma

“Physicians Fighting Stigma: Judgement-Free Scripting for Stages of Change in Opioid Use Disorder” is a series of brief videos (less than 3 minutes each), presented by Bobby Redwood, MD. with the Superior Health Quality Alliance.

Performing Root Cause Analysis (RCA) with Performance Improvement Projects (PIPs)

Overview: A Root Cause Analysis (RCA) is a structured, facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions. The RCA process provides a way to identify breakdowns in processes and systems that contributed to the event and how to prevent future events.

Reason’s Model of Accident Causation: aka The Swiss Cheese Model

The purpose of a RCA is to find out what happened, why it happened, and determine what changes need to be made. It can be an early step in a PIP, helping to identify what needs to be changed to improve performance.
Once you have identified changes that need to be made, the steps you will follow are those you would use in any type of PIP.

Use this Step-by-Step Guide for Performing Root Cause Analysis with Performance Improvement Teams to investigate events in your facility (e.g., adverse event, incident, near miss, complaint).

Download this fillable RCA PIP Team Template to track progress toward process improvements.

“Every system is perfectly designed to get the results it gets.” – W Edwards Deming

NOTE: Facilities accredited by the Joint Commission or in states
with regulations governing completion of RCAs should refer to those requirements to ensure all necessary steps are followed.

LINKS Portfolio: Sepsis

The IPRO QIN-QIO has prepared LINKS (Local Interactive Network of Knowledge Sharers) education materials and guidance to help spread awareness about health topics relevant to your community members, to support population health.

Sepsis: What You Need to Know

Help spread awareness about what sepsis is and what patients/community members can do to prevent it with this fact sheet.

https://drive.google.com/file/d/1lL2kbgezd1LH-t3CzkIn7jkPXRqAH08x/view?usp=share_link

Sepsis: Staying Healthy Through Awareness

This PowerPoint presentation is about what sepsis is, how to help prevent sepsis, and ways to build awareness about it for patients/consumers. The presentation slides can be adapted to fit the needs of your specific audience or community.

https://docs.google.com/presentation/d/19lAkuBfhb54DpnrmKhjltENQ8EV20hSW/edit?usp=share_link&ouid=103685187999998386862&rtpof=true&sd=true