Performing The ACA

When a patient's safety is compromised because of an adverse event, clinical team leaders may be tasked with performing an Apparent Cause Analysis. When done successfully, this process can prevent significant harm to patients and staff and can lead to insights that improve many other areas of hospital operations.

...But this process wasn't being done successfully. So, the Patient Safety Team requested I build a new training to improve performance. I started with a needs analysis - gathering information, evaluating existing instructional materials, and clarifying goals.

I found that the ACA process is extensive and requires significant time for information gathering and documentation. In addition, instructions were incomplete and language wasn't consistent across documents and forms.

The process also requires both inductive and deductive reasoning skills to be applied to several decision-making frameworks in order to be done properly. Training on this aspect of the ACA wasn't yet adequate.

The Solution

After a thorough needs analysis, I proposed an eLearning course with varied types of instruction and heavy learner involvement. Interactions and an immersive patient scenario are the anchors of the training portion, and a new patient scenario comprises the final assessment.

I also proposed and created a pdf job aid, SharePoint site improvements, and a new ACA documentation template to give leaders quick and concise access to the process as needed, and to make language and style consistent throughout training and reference materials.

I also had to consider the needs of the learners - In this case, busy clinical team leaders who are suddenly given an unfamiliar project with a deadline. Because of this, I knew the training would need to be extensive, but presented as simply and clearly as possible.

I also knew the training must be motivating to the leaders, helping them experience why the ACA is important (not just telling them through text). So the training walks them through a simulated situation as practice before their actual ACA.

The Result

Patient Safety reported improvements in the time spent by leaders learning and performing the ACA process. Patient Safety experienced less technical documentation problems, less requests for help, and more thorough on-time ACAs. Many leaders even chose to take the training voluntarily, before ever needing to perform an ACA.

This was one of my favorite projects!

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