News

The term "sentinel event" has become of the term of art in the healthcare industry related to patient safety. The Joint Commission defines a sentinel event as^[1] "...a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in any of the following:

1. Death;
2. Permanent harm;
3. Severe temporary harm."

For purposes of this webinar, a "sentinel event" is an equivalent occurrence in any workplace that represents substantial harm to any stakeholder and/or the organization’s mission. A common managerial response in these situations is to focus on the “last chance” decisions that often confront rank-and-file employees as the cause of the event. This approach fails to consider the systemic issues related to these untoward outcomes.

This presentation will consider the use of root cause analysis as a tool to identify systemic causes designed to avoid future occurrences, not simply finding immediate blame.

Agenda

1. Introductory remarks
2. Example: Systemic harm but individual blame
3. The Root Cause Analysis process
4. The five “Whys”
5. Creating Solutions

SHRM/HRCI Recertification Credits: Approval pending

About the Presenters

Clarence J. Sundram, JD, is a nationally recognized expert on conditions in institutions and community programs for persons with mental disabilities. Currently, he serves as the Independent Monitor for the federal court overseeing the implementation of a Settlement Agreement class action which offers approximately 4000 persons with mental illness residing in adult homes in NYC the opportunity to move to supported housing with support services. Mr. Sundram’s reports to the Court have influenced numerous refinements in the implementation process including the creation of a peer bridger program to be implemented in 22 impacted adult homes.

In March 2011, Governor Andrew Cuomo asked Mr. Sundram to serve as Special Advisor to the Governor for Vulnerable Persons to help address the issue of abuse and neglect of persons in residential care. The report he made to the Governor in April 2012 “The Measure Of A Society: Protection Of Vulnerable  Persons In Residential Facilities Against Abuse & Neglect” recommended sweeping reforms in the system for prevention, reporting, investigating, and responding to such incidents in New York. Governor Cuomo proposed and the legislature unanimously adopted The Protection of People with Special Needs Act, implementing the key recommendations of the report, on June 20, 2012.

For 20 years, he served as the founding Chairman of the New York State Commission on Quality of Care for the Mentally Disabled, an independent state oversight agency charged with advising the governor and legislature, investigating deaths, child abuse, patient abuse, and financial fraud and abuse in programs serving persons with mental disabilities. Mr. Sundram has also served as a member of the Board of Directors of the National Association of Protection & Advocacy Systems (now National Disability Rights Network).

Mr. Sundram received a Juris Doctor degree from the University of Buffalo Law School and a B.A. in English and Philosophy from Niagara University.

Antone Aboud, Ph.D. is a Professor of Practice at the School of Labor and Employment Relations at Penn State. He is the School’s Director of Online Programs. In that capacity, he is not only involved in the daily management of the online programs but also actively involved in course creation and revision processes. He is also and Director of the Center for Workplace Performance, the School’s management outreach platform.

Antone received a B.A. degree in Government from Cornell University, and a Ph.D. in Collective Bargaining, Labor Law, and Labor History from the ILR School at Cornell. Originally, he worked full-time in SUNY's Office of Faculty and Staff Relations, became a faculty member at SUNY (Utica/Rome and Potsdam), and then at St. Francis College. In those capacities, he taught Labor Relations, HR Management, Labor Law, Management Theory, and Organizational Behavior. He also served as a labor arbitrator for several years, and as a chief labor negotiator for both unions and employers. For more than two decades he was a full-time management consultant specializing in risk management training and related interventions.