Easy Guide to Clinical Incident Management - Step 6. Analysis and action
The purpose of analysis is to understand how and why the incident occurred, and to identify ways of preventing a recurrence. The analysis should take into account all information gathered during the Investigation and Classification phases. Actions and recommendations are developed to prevent recurrence of the incident.
Analysing known information about an incident provides a clear indication of the action that should be taken. For example, if the incident is a falls issue, actions could include:
- conducting bedside patient handovers
- ensuring staff have been trained in fall risk assessment
- writing care pathways
- scheduling regular team meetings where incidents are discussed and inquiries are made about staff knowledge levels.
Just as there are many ways in which an incident can occur, there are many actions that can be taken to achieve improvement. Some may need to be applied across the whole organisation, while others may be specific to the incident. How do you decide which avenue to pursue?
Hierarchy of actions
| Stronger actions |
Intermediate actions |
Weaker actions |
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The S.M.A.R.T. system of goal setting
A useful tool for goal setting is the S.M.A.R.T. system of goal setting. You can find out a lot about it on the Internet, but basically, it's a set of actions that enable you to structure an action plan.| S | pecific |
A specific goal has a much greater chance of being accomplished than a general goal. To set a specific goal, answer the six "W" questions:
For example, .... [ a clinical example] |
| M | easurable | Establish concrete criteria for measuring progress toward the attainment of each goal you set. When you measure your progress, you stay on track, reach your target dates, and experience the achievement that spurs you on to the continued effort required to reach your goal. To determine if your goal is measurable, ask questions such as How much? How many? How will I know when it is accomplished? |
| A | ttainable | When you identify goals that are most important to you, you begin to figure out ways you can make them come true. An attainable goal is a goal for which you see a realistic path to achievement, and reasonable odds that you get there. |
| R | ealistic | To be realistic, a goal must represent an objective toward which you are both willing and able to work. A goal can be both high and realistic; you are the only one who can decide just how high your goal should be. But be sure that every goal represents substantial progress. A high goal is frequently easier to reach than a low one because a low goal exerts low motivational force. Some of the hardest jobs you ever accomplished actually seem easy simply because they were a labor of love. Your goal is probably realistic if you truly believe that it can be accomplished. Additional ways to know if your goal is realistic is to determine if you have accomplished anything similar in the past or ask yourself what conditions would have to exist to accomplish this goal. |
| T | imely | A goal should be grounded within a time frame and an end date. |
Taking action...
... may involve escalating the issue. For instance, if a unit manager identified the need for standardised glucose testing machines, the action required may be to prepare a business case and refer it up the administration ladder.