September 5 , 2003

JCAHO tip of the week

Surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will be visiting the MGH Sept. 15 through 19. In preparation for the survey, Hotline is featuring a tip of the week. The tip contains information that all MGHers should know for the survey.

For more information, visit the MGH JCAHO website at http://is.partners.org/jcaho/

Failure Mode and Effect Analysis (FMEA)

1. Failure Mode and Effect Analysis (FMEA) is a proactive risk reduction system that identifies and improves steps in a process, thereby reasonably ensuring a safe and clinically desirable outcome. 

2.  FMEA is a preventive technique, rather than an after-the-fact fix and serves as a tool for significantly improving patient safety. 

3. The first FMEA the MGH pursued was the anti-coagulation initiative.

 What is the methodology for performing FMEAs?

1. An organization needs to define the FMEA topic, using past experiences and processes that affect patient care.

2. Hospital leadership assembles a multidisciplinary team to lead the effort, with at least one content expert. The team will map out the process flow to identify points where failure may occur.

3. Next, the team conducts a hazard analysis, identifying failure modes in process and rating each for probability and severity.

4. Following the hazard analysis, the team identifies  failure modes that require correction.

5. Finally, the team takes appropriate actions to correct failure modes, develop prevention strategies and measure outcomes.