Root cause analysis in a multiprofessional environment Copyright © Healthcare Quality Quest, 2013

Our experience teaching root cause analysis (RCA) Our approach to RCA Key issues that engage clinical teams Feedback from learners

Our experience teaching root cause analysis (RCA) Our approach to RCA Key issues that engage clinical teams Feedback from learners

Teaching RCA — Response to requests from healthcare organizations Started in 1990s, primarily for nurse managers Provided over 80 workshops on RCA (and include RCA in clinical governance courses) In 2013, 3 workshops for specialty registrars and others and 13 others for multiprofessional groups Since 2007, we provide RCA workshops principally for multiprofessional groups and they work as teams in the workshop

Our experience teaching root cause analysis (RCA) Our approach to RCA Key issues that engage clinical teams Feedback from learners

Characteristics of RCA education — Accommodates the international evidence base on the known weaknesses of RCA Learners are involved in doing an RCA on a real incident Purpose is to prevent recurrence of the same incident Systems — not people — are analysed Multiple causes are searched for Actions are prioritized by probability of effectiveness Plans are made to measure the impact of actions RCA does not stop with recommendations and a report!

Root cause analysis stages — S–O–L–V–E–D 1. S eek all the facts related to the event S 2.O btain and preserve relevant materials O 3.L earn the relevant processes or systems L 4.V alidate analysis of the causes of the breakdown in the processes V 5.E stablish and implement action needed to reduce the probability of recurrence E 6.D etermine the effectiveness of the actions taken D

It… is (too) complex out-of-date unrealistic to implement doesn’t exist Intended or authorized The processes to learn — and what we learn It… has shortcuts is what staff used to do in other jobs accounts for out-of-date policies involves ‘optimizing’ by staff Usual It can be any variation from intended or usual… Actual in the incident

Our experience teaching root cause analysis (RCA) Our approach to RCA Key issues that engage clinical teams Feedback from learners

What engages clinical teams about RCA Colleagues asking useful questions about ‘the story’ that opens up thinking about the context for an incident (more than the incident report) Colleagues raising more ‘lines of inquiry’ The process analysis — the need for a rethink on everything about policies and procedures (development, testing, dissemination, production, access, indexing and search functions, explicit recognition of exceptions, etc Insight on the role of ‘custom and practice’ and how unsafe it can be (ward rounds)

Many processes are profession-specific and not integrated and patient centered Unnecessary variation in practices in critical situations Thinking creatively about effective and realistic actions that will sustain change (clever system changes, not ‘reminding staff’ to do it) The challenge of producing evidence of risk reduction How complex healthcare is — and how interesting it is to think about how to make it safer for patients

Our experience teaching root cause analysis (RCA) Our approach to RCA Key issues that engage clinical teams Feedback from learners

Common comments about what was useful ‘Process and procedures analysis’ ‘Working through a case as a group’, ‘discussion with other team members as they brought up points I hadn’t considered’ ‘How to dissect causes and contributing factors for an incident’ ‘Having a systematic way to use tools to analyse an incident’ ‘System for identifying effective actions’

Conclusions Much better analysis of root causes of incidents or near misses by a multiprofessional team Real interest by all team members, including doctors, in true root causes of serious incidents More insight into the challenges of achieving improvements in patient safety — multiprofessional support needed Consensus on effective actions to be taken to achieve sustained patient safety improvements

Our experience teaching root cause analysis (RCA) Our approach to RCA Key issues that engage clinical teams Feedback from learners

Nancy Dixon Healthcare Quality Quest