Hawai'i-Pacific Chapter
A quarterly e-newsletter for the Hawai'i Pacific Chapter of ACHE Fall 2015 Newsletter
In This Issue
Message from your ACHE Regent, Fall 2015
Message from the Chapter President
Recent Chapter Events
Chapter Awards
News from the Education Committee
Membership: New Fellows, Members, and Recertified Fellows
Calendar of Events for Fall 2015
Education Calendar for Fall 2015
Fall 2015 Financial Report
National News - Fall 2015
Articles of Interest
The Failure Modes Effect Analysis Process in Healthcare
Back to Basics: Emphasizing Progressive Mobility in the Inpatient Setting
Semper Gumby: Leadership Lessons Learned Aboard the World’s Largest Floating Hospital
Career Development
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Leadership Strategies
Healthcare Finance and Analysis
Strategic Planning
Diversity and Inclusion
Healthcare Quality Improvement
Government Policy


Jen Chahanovich, FACHE

Gidget Ruscetta, FACHE

Art Gladstone, FACHE

LT Joseph Fromknecht


Selma Yamamoto

Natalie Pagoria

Art Gladstone, FACHE

Micah Ewing

MAJ Charlotte Hildebrand, FACHE

Lt. John Piccone

Nick Hughey

Jennifer Dacumos

Stella Laroza


Darlena Chadwick, FACHE


The Failure Modes Effect Analysis Process in Healthcare
Richard Giardina RN, MPH, CIC, FACHE

Failure Mode Effects Analysis (FMEA) was first used by the military in 1949, NASA in the 1970s, and the Automotive Industry Action Group in the 1990s. (1)  The Joint Commission has recommended that health care facilities use the FMEA process to identify risk and develop an action plan for any new process before it is implemented.


FMEA is a structured way to identify and address potential problems, or failures and their resulting effects on the system or process before an adverse event occurs. In comparison, Root Cause Analysis (RCA) is a structured way to address problems after they occur; the FMEA addresses problems before they occur


FMEA is effective in evaluating both new and existing processes and systems. For new processes, it identifies potential bottlenecks or unintended consequences prior to implementation. It is also helpful for evaluating an existing system or process to understand how proposed changes will impact the system. Once you have identified what changes need to be made to the process or system, the steps you follow are those you would use in any type of performance improvement plan.

Below are the steps of the FMEA:
1. Select a process to analyze
2. Charter and select team facilitator and team members
3. Describe the process
4. Identify what could go wrong during each step of the  process
5. Pick which problems to work on eliminating
6. Design and implement changes to reduce or prevent problems
7. Measure the success of process changes


If not careful in selecting the correct process to analyze, an FMEA can be daunting and cost considerable time. Narrow the scope of FMEA as much as possible. For instance, when facilities try to do a project on a complex process such as medication administration the team often finds there are too many variables to take into account. The administration process can vary by unit, by type of medication, by time of day, and so on. It is best to narrow the focus. For instance, do FMEA on administration of a particular type of high-risk medication or a project on medication administration for a category of residents vulnerable to safety problems.

The Institute for Healthcare Improvement (IHI) website contains a template for the FMEA process. (http://www.ihi.org/resources/pages/tools/failuremodesandeffectsanalysistool.aspx  ). Risk factors and likelihood of their occurrence are entered onto a worksheet.  Higher-scored items are given priority for an improvement plan. (2) 

1. https://en.wikipedia.org/wiki/Failure_mode_and_effects_analysis  last accessed 9/14/15.
http://www.ihi.org/resources/pages/tools/failuremodesandeffectsanalysistool.aspx last accessed 9/14/15.

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October Educational Conference:  October 7-8, 2015 

"Practical Leadership Strategies in an Age of Change, by Carson Dye.
Queen's Hospital - Queen's Conference Center 

(12) Face-to-Face Credits for only $500.00!
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AONE Conference:  November 5-6, 2015

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