Sağlık hizmetlerinde kök neden analizi: 21 Adım Uygulaması
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Dosyalar
Tarih
2020
Yazarlar
Dergi Başlığı
Dergi ISSN
Cilt Başlığı
Yayıncı
Düzce Üniversitesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Ortak Komisyon (Joint Commission - JC), kök neden analizi için 4 bölüm 21 adımdan oluşan bir metodoloji sunmuştur. JC'nin 21 adım uygulamasının, uygulanabilirliğini değerlendirmek amacıyla gerçekleştirilen bu araştırmada, bir üniversite hastanesinin, biyokimya- mikrobiyoloji laboratuvarında reddedilen numunelerin nedenleri üzerinde bir uygulaması gerçekleştirilmiştir. 21 adım yöntemi ile birlikte; "Gantt Çizelgesi", "Beyin Fırtınası", "Akış Şeması", "Balık Kılçığı Diyagramı" ve "Hata Türleri ve Etkileri Analizi", kalite iyileştirme teknik ve araçları da kullanılmıştır. Ayrıca, bir "Eylem Hiyerarşisi" aracı kullanılarak iyileştirme eylemlerinin gücü derecelendirilmiştir. Uygulama sonucunda, reddedilen numunelerin kök nedenleri; oryantasyon ve eğitim uygulamaları yetersizliği, politika ve prosedürlerin uygulanabilirliği, izleme ve değerlendirme eksikliği, verimsiz süreç akışı ve ekipman eksikliği olarak belirlenmiştir. Belirlenen bu kök nedenlere yönelik, 5'i (%45,5) güçlü, 3'ü (%27,3) orta düzey diğer 3'ü (%27,3) de zayıf eylem olmak üzere toplamda 11 tane iyileştirme eylemi belirlenmiş ve planlanmıştır. Genel olarak, gerçekleştirilen çalışmada 21 adım metodolojisinin, bir sorunun doğrudan, katkıda bulunan, altta yatan ve kök nedenlerini belirlemede ve kök nedenlerine yönelik iyileştirme eylemlerini planlamada, ayrıntılı bir rehberlik sunarak yardımcı olacağı görülmüştür. Gerçekleştirilen Hata türleri ve Etkileri Analizinde sunulan temel önlemlerle genel olarak risk puanlarında yaklaşık %64,5'lik azalış olacağı öngörülmüştür.
JC (Joint Commission) has provided a methodology consisting of 4 sections and 21 steps for root cause analysis. In this research, which was carried out to evaluate the applicability of JCs 21 step implementation, it was tried to demonstrate the applicability of a university hospital on the causes of the samples rejected in the biochemistry-microbiology laboratory. Along with the method; "Gantt Chart", "Brainstorming", "Flow Chart", "Fishbone Diagram", "Failure Mode and Effects Analysis", quality improvement techniques and tools were used. In addition, the strength of improvement actions is rated by using an "Action Hierarchy" tool. As a result of the application; the root causes of the rejected samples were determined as insufficient orientation and training practices, applicability of policies and procedures, lack of monitoring and evaluation, inefficient process flow, and lack of equipment. For these identified root causes, a total of 11 improvement actions were determined where 5 (45.5%) strong, 3 (27.3%) intermediate, and 3 (27.3%) were weak actions. An action plan has been developed for these actions. Overall, it was found that the 21 step methodology, carried out in the study, would assist in identifying direct, contributing, underlying and root causes of a problem and planning improvement actions for root causes by providing detailed guidance. With the basic measures presented in the Failure Mode and Effects Analysis, it is foreseen that there will be a 64.5% decrease in overall risk scores.
JC (Joint Commission) has provided a methodology consisting of 4 sections and 21 steps for root cause analysis. In this research, which was carried out to evaluate the applicability of JCs 21 step implementation, it was tried to demonstrate the applicability of a university hospital on the causes of the samples rejected in the biochemistry-microbiology laboratory. Along with the method; "Gantt Chart", "Brainstorming", "Flow Chart", "Fishbone Diagram", "Failure Mode and Effects Analysis", quality improvement techniques and tools were used. In addition, the strength of improvement actions is rated by using an "Action Hierarchy" tool. As a result of the application; the root causes of the rejected samples were determined as insufficient orientation and training practices, applicability of policies and procedures, lack of monitoring and evaluation, inefficient process flow, and lack of equipment. For these identified root causes, a total of 11 improvement actions were determined where 5 (45.5%) strong, 3 (27.3%) intermediate, and 3 (27.3%) were weak actions. An action plan has been developed for these actions. Overall, it was found that the 21 step methodology, carried out in the study, would assist in identifying direct, contributing, underlying and root causes of a problem and planning improvement actions for root causes by providing detailed guidance. With the basic measures presented in the Failure Mode and Effects Analysis, it is foreseen that there will be a 64.5% decrease in overall risk scores.
Açıklama
YÖK Tez No: 634285
Anahtar Kelimeler
Sağlık Kurumları Yönetimi, Health Care Management, Hata türleri ve etkileri analizi, Failure mode and effect analysis, Kalite teknikleri, Quality techniques, Kök Neden Analizi, Hata Türleri ve Etkileri Analizi, Kalite Araçları, Tıbbi Laboratuvar Hizmetleri, Reddedilen Numune, Root Cause Analysis, Failure Mode and Effects Analysis, Quality Tools, Clinical Laboratory Services, Rejected Samples
