Simplified FMEA ( F ailure M ode E ffect A nalysis)

1. Simplified FMEA(Failure Mode Effect Analysis) • A systematic method to identify process problems/breakdowns that may result in the inability to achieve desired outcomes consistently. • Ideally data is collected to understand the frequency & importance of each problem. • The tool can be used on an existing process or a newly designed process.

2. Simplified FMEA (Failure Mode Effect Analysis) • Create a high level process map/flow chart • Through brainstorming with your team, identify possible causes of failures for each high level process step • Ideally, you would collect data to identify the frequency of each cause • Ideally, you would rate how critical each possible failure is re its effect on the desired outcome of the process

3. CURRENT PROCESS

4. CURRENT PROCESS Guideline eligible patient not identified a) RNs and other care providers including parents may not be aware of, or agree with, recommendation b) RNs and other care providers don’t know how process is performing • MDs may not be aware of or agree with, recommendation • MDs don’t know how process is performing • MDs not sure what the process is Appropriate education not provided a) Care providers don’t comply with order set • Care providers roles/ responsibilities not clear c) Care providers lack competence in delivery of recommended care • No process to identify real-time failures & mitigate • Care providers not sure what the process is a MDs select wrong orders • MDs don’t know order set exists • MDs don’t use order set • MDs find order set difficult to use FAILURE MODES

5. EVIDENCE-BASED CARE DELIVERY FOR INPATIENTS • Shared assessment tools • Unit tracks outcomes & failure real time • Care can be started by RT or RN based on protocol • Low risk treatments become default action a) Order sets – (Revise as appropriate) • Decision support for Order Set • Pathways • Ongoing work by CE Education Coordinator • Data Feedback to Physicians PLANNED IMPROVEMENTS • Ongoing work by Unit Education coordinators • Data Feedback to staff • Parent awareness Patient Identified at outset Evidence-Based Family Education CURRENT PROCESS PATIENT ARRIVES ON UNIT ORDERS ENTERED FULL ASSESSMENT BY RN PATIENT DISCHARGED CARE INITIATED FULL ASSESSMENT BY MD Appropriate education not provided a MD’s select wrong orders • MD’s don’t know order set exists • MDs don’t use order set • MD’s find order set difficult to use a) Care providers don’t comply with order set b) Care providers roles/ responsibilities not clear • Care providers lack competence in delivery of recommended care • No process to identify real-time failures & mitigate • Care providers not sure what the process is • MD’s may not be aware of or agree with, recommenda -tion • MD’s don’t know how process is performing • MD’s not sure what the process is a) RN’s and other care providers including parents may not be aware of, or agree with, recommendation b) RN’s and other care providers don’t know how process is performing Guideline eligible patient not identified FAILURE MODES

6. Simplified Failure Modes Effects Analysis: Insert description of your process Potential Solution PROCESS Barriers