Conducting A Root Cause Analysis Nina Shik, MSN, RN, NEA-BC, CIC Director of Epidemiology North Shore University Hospital Manhasset, NY

North Shore University Hospital NSUH is an 804-bed quaternary teaching hospital in Manhasset, NY. NSUH is a Level 1 Trauma Center with 5 Adult ICUs and a Level-3 NICU. It is the largest hospital in the North Shore-LIJ Health System.

My Role 22 years of experience in Infection Prevention Director of the NSUH’s Infection Prevention program since November 2012 Report to Hospital’s Associate Executive Director of Quality and System VP of Infection Prevention Lead a team of 6 Infection Preventionists Work with IPs from across the NS-LIJ System

Root Cause Analysis (RCA) RCA is a systematic, formalized approach to review an adverse event and identify root causes RCA provides a forum for key individuals to: focus on a problem come to consensus about factors leading to the problem develop effective corrective actions

Root Causes Specific factors leading to adverse events Help identify what, how and why an event occurred Are specific and based upon factors that can be modified Identifying “snow storm” as the reason staff were not available to provide patient care is not specific enough. We can’t control the weather.

Not a “Stand Alone” Solution RCA is a strategy that complements other quality improvement activities RCA is most effective within a comprehensive safety program

RCA Steps Develop a core team that is invited to every RCA. For an HAI RCA this includes: Chief Medical Officer, Associate Executive Director of Quality, Infection Preventionists, Infectious Diseases Chair and the Medical and Nursing Directors for area being reviewed For each meeting invite other participants depending on type of issue being addressed Always include care providers who were involved in event Cast a wide net

Before the RCA Meeting Outline a step-by-step process leading up to, during and after the RCA meeting, including: Who leads the meeting Who takes minutes Who provides patient information during the RCA and what information they are expected to share Who researches and shares applicable standards for care Who develops action items, based upon root causes Who implements the action items Who collects data to determine efficacy of interventions How to determine if interventions are effective

Before our Meetings IP identifies HAI, based on NHSN definitions Nurse Manager review patient record to determine who should attend RCA IP Director contacts the attending physician and Chair of Infectious Diseases to discuss the event and the RCA process IP Director sends list of meeting participants to Quality Department Quality organizes the meeting and invitations

During our Meetings Chair of Infectious Diseases chairs the meeting Attending Physician presents the patient’s case Infection Preventionist presents the HAI history Care providers present patient-specific HAI clinical information The group discusses the case and identifies causative factors

At the End of the Meeting The Chair summarizes discussion points The group determines action items The action plan is written down Goals are established (e.g., decrease CAUTI on the unit by 50% in the next 3 months) Data collection method is determined Follow up time frame is established

After the Meeting Action plans are implemented Follow-up data are collected Data are reviewed and share with key players and relevant committees If results are positive we may decide to spread the interventions to other units If results are not as hoped we conduct additional RCAs

Getting to the Root Cause Make sure that the right people are in the room Ensure a safe, non-punitive environment Start with an overview of the processes related to the event Focus on issues, not individuals Let everyone provide input, but keep the focus on the event and related processes.

Questions to Consider What happened? When and where did the occur? What are usual, recommended processes/practices for this type of care/device/procedure? Were all steps followed, in the correct order? Were all providers trained and competent? Are there other factors to bring up?

Helpful Tools Fishbone diagram is helpful to keep focus on evidence-based risk factors. Fishbone “spines” often include: Patient-specific factors Caregiver factors Equipment factors Environmental factors Systems factors

Pre-populated Fishbone If factors contributing to a problem are well defined in the literature it may be helpful to use a prepared Fishbone Diagram that includes these factors Contributing causes of CAUTI are well-recognized, so we use a pre-populated Fishbone for CAUTI RCAs that IPRO provided It ensures a consistent review and consideration of all relevant risk factors

IPRO CAUTI Fishbone

“5 Whys” of Problem Solving Using 5 Whys helps us to think beyond obvious “gut feeling” aspects of a problem to get to root causes Allows different ideas to be expressed Encourages every participant to provide input

“5 Whys” Example Why do you think the CAUTI occurred? Why? The catheter was left in longer than needed Why? An order to remove it was not written The nurse and doctor forgot to discuss the need for the catheter during rounds Their rounding tool does not address urinary catheters The tool was just revised and the urinary catheter daily assessment section was inadvertently deleted

Action Plan You may identify several root causes Suggestions for improvement should be discussed for each one By the end of the meeting a list of action items should be developed, with identified “champions” and a time line for completion Some items may need to be addressed by a smaller working group or hospital administrators

Support and Follow-Up A high level of energy usually occurs after a successful RCA Staff are motivated to make identified changes Provide resources to support them Collect data to determine if the changes are effective Share data with RCA participants Celebrate successes!

Benefits of RCA A successful RCA program: Increases collaboration and sharing of information Allocates resources to meaningful root causes Encourages accountability and follow-up on all levels Identifies solutions to share with other areas of your facility/system Promotes a culture of safety

NSUH CLABSI RCAs Part of a comprehensive CLABSI prevention initiative Rates decreased, but did not reach zero until RCA’s were formalized and expanded to include more physicians At a recent luncheon to celebrate zero CLABSIs our Chair of Infectious Diseases remarked that the best thing about zero CLABSIs, in addition to patient benefits, was not having to attend RCA meetings!

References Rooney, J. J., & Heuvel, L. N. V. (2004). Root cause analysis for beginners. Quality progress, 37(7), 45-56. Zidel, T. G. (2006). A Lean toolbox: Using Lean principles and techniques in healthcare. J Healthc Qual, 28(1), W1-7. IPRO Root Cause Analysis Toolkit qio.ipro.org/wp-content/.../12/7_1-12-14_RCA_Toolkit_final.pdf

? Questions? Thank you for your attention I can be contacted at nshik@nshs.edu