9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

CopyofPhysicalTherapyAdmission
LakeviewHospital
Stillwater,Minnesota,UnitedStates
Other

Aim:ToreducetheriskprioritynumberforPhysicalTherapyAdmitprocessby50%in6months.
ProcessData
Date:11/27/2009
Step

Description

IntakenotifiesLori/designeeofreferral

FailureMode

Causes

Intakeclincianfailstonotify
Lori.
Confusionistowhothe
designeeisoccurs

Confusion/inattentiveness
Clientisnotadmittedina
overintakeprocesswhenPT timelyfashion.
isinvolved.
Morethanoneintakeclincian
andmorethanonedesignee
ispossible,unclearwhois
designee

Step

Description

Lori/designeeassignsPT

Effects

FailureMode

Causes

Effects

Lori/designeeforgetsthis
stepintheprocess

Frequentinterruptionsof
work

Delayintreatingclientmay
occur

Step

Description

Lori/designeecommunicatesassignmenttoclincian(s)involvedand
intakefordistributionofdata

FailureMode

Causes

Effects

Cliniciandoesnotlistento
his/hervoicemail.

Clincianbusyforgetsto
checkvoicemail

Clientisnotadmittedina
timelyfashion

Step

Description

PTcompletesEvalformandpaperOasis,turnintoLori/designee

FailureMode

Causes

Effects

Failedfax

Wrongfaxnumber,
Faxreceivedbutnotrouted
correctly

Delayindataentryleadingto
delayincare

Lori/designeefailstolocate
turnedinpaperwork.

Lori/designeeforgetthatthis Delayincompleting
paperworkisexpectedin.
paperwork
Paperworkisplacedinwrong
mailbox.

Step

Description

PTwillcommunicateclientadmissionandpocviaclinician
communicationline

FailureMode

Causes

Effects

Clinicianforgetstoleave
message

Busy,forgets

Failureforrestofteamto
haveuptodateinformation
onnewclient's,mayleadto
decreasedptoutcomes

Step

Description

Lori/designeereviewsandroutesallvisitsandevalstoMonica,who
willentervisitandmileage

FailureMode

Causes

Effects

visitandevalsdonotreach
Monica
Monicamisplacespaperwork
beforedataentry

Lori/designeemisplaces
paperwork
Busy,interruptions

Failureforcliniciantobe
paid.Failureforagencytobe
paid.

Step

Description

Lori/designeedataenterscodingsummaryon485fromPT'seval
sendscodingworksheettoPatti/Kim

FailureMode

Causes

Effects

IfPatti/Kim/Sueareoff

poorvacationplanning

Incorrectcodingleadingto
inaccurateA/R

Occ Det Sev RPN Actions

3

36 Oneprocessformtofollow
fromintaketowhen
admissioniscompleted.
DesigneewhenLoriisnot
availablewillbeJanet.

Occ Det Sev RPN Actions

1

4 Intakeinitiatesprocessform
tofollowclient

Occ Det Sev RPN Actions

1

5 Clincianchecksinwith
intake/staffingtoverify
scheduleeachday.

Occ Det Sev RPN Actions

3

15 Placefaxnumberoneval
form.
Intakewillroutecopyof
faxedformsto
Lori/designee.
4 Alltherapyclient'sareadded
tothetherapyroundsform.
Lori/designeereceivesthe
referralprocessformon
eachnewPTreferral.

Occ Det Sev RPN Actions

2

6 PTclientstobeaddedto
therapyroundsform.

Occ Det Sev RPN Actions

1

2 FollowPTintakeprocess
form

Occ Det Sev RPN Actions

1

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=9855&ScenarioId=11428&Type=1

2 Managerstodiscussvacation
approvals.

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

Step

Description

Lori/designeeenterscodeswhencodingsheetcompleted

FailureMode

Causes

Effects

Inaccuratedataentryinto
CareFacts.
Codingsheetisnotreturned
toLori/designee

Humanerror
Failuretofollowprocedure

Inaccuratecoding
informationleadingto
inaccuratebilling

Step

Description

Lori/designeecomplete485,andentersummaryandgoalspereval
infoandfaxtoPT

FailureMode

Causes

Lori/designeefailstoenter
summaryandgoals
secondarytonotreceiving
paperwork

Breakinthechainofprocess Incompleteplanofcare
withthepaperwork,many
peopleinvolvedinprocess

Effects

Step

Description

10

PTwillfaxbackcopywithapproval/changesandthen485is
forwardedtoMedRec.

FailureMode

Causes

Effects

PTdidnotreceivefaxed
copies.
Lori/designeedoesnot
receivefaxedbackcopies.

Faxmachinemisfunction
Humanerror

Delayinpaperwork,failureto
meetregulatoryguidlelines.

Step

Description

11

Lori/designeeopensavisitandenterinOasisdataperevalinfo.any
questionssenttoclinician

FailureMode

Causes

Effects

Lori/designeefailstoreceive PTfailstoreturncompleted
Latedataentryleadingto
paperworkleadingtofailure evalandOasisinformationto delayininformationforother
ofdataentry.
Lori/designee
caregiverstouseintreating
client.
Step

Description

12

Lori/designeeenterscareplanintoCareFactsperPTevalandin
consultationwiththerapyservices

FailureMode

Causes

Lori/designeefailstoreceive Humanerror
paperwork.
Complicatedprocess
Lori/designeefailstoinput
data
PTfailstosendpaperworkto
Lori/desginee
Step

Description

13

Clienttobecaseconferencedwithin5days.

Effects
Lackofdocumentedplanof
carewithinCareFactsfor
otherclinicianstouse

FailureMode

Causes

Clientnotaddedtocase
conferencinglist,orPT
roundslist

Lackofcommunication/follow Poorcomprehensiveplanof
up
carewhichcouldleadto
pooreroutcomes

Effects

Step

Description

14

Lori/designeesendsalladmissionpaperworktoMedRec

FailureMode

Causes

Effects

Paperworkislostinthe
varioussteps.

Complicatedprocedure.

Lossofpaperwork,poor
regulatorycompliance

Step

Description

15

Oncecomprehensiveevaldone,PTwillnotifyLori/designeetolock
Oasis

FailureMode

Causes

Effects

Failureforcomprehensive
evaltobecompletedwithin
the5daywindow,delayin
PTreceivingcomprehensive
evalinfoandnotifying
Lori/designeetolock

ParttimePTemployeenot
oftenonsite,whoisnot
trainedinsoftware.

Complicatedprocedure,
delaysandinformationnotas
readibleaccessible.

Occ Det Sev RPN Actions

1

2 AdmittingPTtoreviewcodes
foraccuracy

Occ Det Sev RPN Actions

1

3 Intakegivescopyofreferral
toLori/designeeafterfaxing
toPT

Occ Det Sev RPN Actions

1

2 IntaketostartthePT
referralprocesspaperwork
andLori/designeetofollow
daily

Occ Det Sev RPN Actions

1

2 IntaketostartPTreferral
processform

Occ Det Sev RPN Actions

1

2 IntaketobeginPTreferral
processformandforwardto
Lori/designee.

Occ Det Sev RPN Actions

1

6 IntaketoinitiatePTreferral
formandforwardto
Lori/designeeafterfaxingto
PT

Occ Det Sev RPN Actions

2

2 Addacheckofflistforeach
formtoPTreferralprocess
form.

Occ Det Sev RPN Actions

2

8 WhenabletrainPT
employeesonCareFacts
software.FollowPTreferral
formdaily.

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

101

Occ: LikelihoodofOccurrence(110)
Det: LikelihoodofDetection(110)
NOTE: 1=VerylikelyitWILLbedetected

10=VerylikelyitWILLNOTbedetected

Sev: Severity(110)
RPN:RiskPriorityNumber(OccDetSev)

Annotation

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=9855&ScenarioId=11428&Type=1

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InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

None

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=9855&ScenarioId=11428&Type=1

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