1. Identifying Problems Care and Service Delivery Problems (CDPs + SDPs)
Concept of care and service delivery problems - Vincent and Adams (1999)

2. The RCA Process Getting Started
Gathering Information & Mapping the Incident
Identifying Care & Service Delivery Problems
Analysing Problems & Identifying CFs and RCs
Generating Solutions & Recommendations
Identify Care + Service delivery problems – Compare what should have happened against what actually happened. i.e identify what happened that shouldn’t have, or what didn’t happen that should have. (BUT DON’T STOP THERE)
Implementing Solutions
Writing the Report

3. What are Care/Service Delivery Problems (CDP/SDPs)?
Every point where:
Something happened that shouldn’t have OR
Something that should have happened, didn’t.
CDP/SDPs

4. Care Delivery Problem (CDP)
Problems that arise in the process of care… …usually actions or omissions by staff
Care Delivery
Problem
(CDP)
care deviated beyond safe limits of practice and
ii the deviation had a direct or indirect effect on the eventual adverse outcome for the patient
Failure to monitor, observe or act
Incorrect decision or action
Not seeking help when necessary

5. Service Delivery Problem (SDP)
Acts or omissions identified during the analysis of the incident, but not associated with direct care provision.
Service
Delivery
Problem
(SDP)
…These are generally associated with decisions, procedures and systems that are part of the whole process of service delivery.
Fail to undertake environmental risk assessment
System for ensuring all new telephones have an emergency
number for switchboard on them

6. How to identify CDPs and SDPs
Some will jump out immediately
Others emerge, particularly when the clinical team involved is invited to contribute
... Never assume your organisation / team is doing what you (or even they!) think they’re doing
Peter Pronovost
You are now at the point where you have mapped the incident fully and it may even have been at that point where you start thinking about what the real problems are in this incident?
Actually, you want to get the stakeholders to come and take a look at your tabular timeline - Do give people the opportunity to contribute at various points in the RCA process.
The next main task for you as an RCA Investigation Team is start thinking about what are the care and service delivery problems? Some of these will jump out at you immediately!! Other results emerge much more slowly particularly if you are having a multi-professional review team involved in the investigation.

7. To determine CDPs and SDPs
Consider holding an Multi Disciplinary Team meeting
This approach is valuable to:-
Clarify your ‘map’ of the incident
Identify CDPs + SDPs and contributory factors
Invite those involved or interested to take part and learn from the process
Gain help finding workable solutions
Share the report and debrief staff on the learning
It can also work well therapeutically
Especially where ‘perceived’ blame issues need to be worked through!
(NB: Wherever reckless, malicious or criminal activity is ‘actually suspected’, these issues are transferred to other experts for action)

8. But… So… And… Tensions may be running high
It may be difficult to get everyone together
So…
Consider seeing people in smaller groups
And…
Practise with a low-harm incidents first

9. Hierarchies - the need for skilled facilitation
When RCA meetings are attended by both medical and nursing staff, they are often dominated by doctors. Nurses feel uneasy about challenging the practice of Doctors
Discussion during RCA meetings is often dominated by consultants. Junior Doctors remain silent and hardly challenge Senior Doctors.
Clinical Governance teams struggle to get responses from clinical personnel to attend meetings. Incidents surface differences between clinical practices and conflicts between clinical departments.
Warwick University Research

10. Tips on Preparing the meeting
Choose a facilitator who enjoys respect and can respectfully challenge clinicians
Be clear about the purpose of the meeting /review
Ensure the right people attend
Send out proper invitations (date, time, venue, agenda)
Find out as much background info. as possible – know your group!
Plan the agenda, tools, techniques, flipchart etc
Decide how to record information and outcomes
Welcome attendees and provide refreshments
Develop contingency plans in case things go wrong
Prepare yourself to facilitate a successful outcome

11. Key Points – Facilitating an MDT
Research shows that this aspect can have a huge bearing on the effectiveness of the whole investigation
Consider gaining advanced training or enlisting the help of an in-house expert

12. RCA tools to help identify CDPs & SPDs
Change
analysis
Nominal group technique

13. Change analysis – the process
Describe the “map” of your incident.
Compare this with normal acceptable practice
(based on national and local policy/guidance)
List the changes.
Did the changes contribute to the incident?
Agree the main problems (CDP/SDPs).
Carefully assess the differences and identify possible underlying causes.
Describe how these affected the event.
Did each difference change or explain the result?

14. Mapping – the chronology of the incident
What actually happened
- Patient journey
Xxx xxxxxxxx
Xxxxx xxxx xxxxxxxxx xxxxxxxx xxxxxc
Xxxxxxxx xxxxxxx xx xxxxxx xxxxx xxxxxx
Xxxxx xxxx xxxxxxxxxx xxxxx xxxx xxxx xxxxxx

15. Mapping – accepted practice
What should have happened
- Policy / Clinical guidelines
Xxx xxxxxxx xxx xxxxxx xxxxxx
Xx xxxx xxxx xxxxxxxxxxx xxxxxxx xxxxxxxxxx
Xxxxx xxxxxx xxxxxxxxxx x xxxxxxxxxxx
Xxxxxxxx xxxx xxxxxx xxxxxxxx x xxxx
What actually happened
- Patient journey
Xxx xxxxxxxx
Xxxxx xxxx xxxxxxxxx xxxxxxxx xxxxxc
Xxxxxxxx xxxxxxx xx xxxxxx xxxxx xxxxxx
Xxxxx xxxx xxxxxxxxxx xxxxx xxxx xxxx xxxxxx

16. Change Analysis – to identify CDPS & SDPs
B. What should have happened
- Policy / Clinical guidelines
Xxx xxxxxxx xxx xxxxxx xxxxxx
Xx xxxx xxxx xxxxxxxxxxx xxxxxxx xxxxxxxxxx
Xxxxx xxxxxx xxxxxxxxxx x xxxxxxxxxxx
Xxxxxxxx xxxx xxxxxx xxxxxxxx x xxxx
A. What actually happened
- Patient journey
Xxx xxxxxxxx
Xxxxx xxxx xxxxxxxxx xxxxxxxx xxxxxc
Xxxxxxxx xxxxxxx xx xxxxxx xxxxx xxxxxx
Xxxxx xxxx xxxxxxxxxx xxxxx xxxx xxxx xxxxxx
1. Variations from acceptable practice
- Care & service delivery problems
Xxxx xxxxxxx xxxxxxxxxxx xxxxxxxxxxxxxxxx
Xxxxxxxxxxxxxxxxxxxx xxxxxxxx xx xxxxxxxxx

17. Worked example
Mr Smith, 48yrs – diabetic steel worker scheduled for Right below knee amputation due to circulatory problems.
Also problems with Left leg requiring amputation at a later date.
After surgery they discovered that the wrong leg had been amputated.

18. Change analysis Normal procedure Incident www.npsa.nhs.uk/rca
Was there a change?
Did change contribute to incident?
Surgeon knew patient’s condition - both feet gangrenous No
Theatre list correct & reviewed by surgeon
after typing
Theatre list changed and hand written by SHO (RIGHT leg not clearly identified)
Yes
Marking of site by surgeon prior to list using skin pencil, after checking with pt and notes
Right calf marked by SHO using Biro when consent form signed. Patient crossed legs & mark transferred to left leg
Preparation & draping carried out by surgeon
Preparation & draping carried out by surgical assistant who did not know patient

19. Changes (CDPs) leading to the incident
SHO produced an unclear hand written theatre list
SHO marked the site using a Biro
Surgical assistant draped limb after reading theatre list and noting site - omitted to check medical records and consent form
Draping not carried out by surgeon
This is a summary of the changes that contributed to the incident.

20. What should your CDPs/SDPs look like?
Specific not vague:
Communication failure X
Paramedic failed to inform A&E patient was confused 
What happened not why:
Not enough training on hand hygiene X
Staff member did not wash or clean his hands 

21. Care should be taken to avoid:-
Hindsight bias =
Judging with the benefit of knowledge others did not have at the time of the incident.
This leads people to make unfair assumptions about staff closest
to the incident.
Outcome bias =
If an error causes no harm it is considered lucky. If the same error causes significant harm we are more likely to blame.
This allows accountability to become inconsistent and unfair.

22. Group work
Verify unconfirmed facts (Try questioning your presenter/facilitator)
Identify CDPs and SDPs
Define the failing not the cause (Use clear & specific phrasing)

23. Why are CDPs and SDPs so important?
To break down the analysis into manageable chunks
To provide a forum for raising / referring perceived blame issues
To ensure that both clinical care + service delivery issues (unsafe acts & conditions) are considered equally as appropriate
To provide a means of prioritising in line with capacity and resource limitations.
NB: To provide a forum for raising / referring perceived blame issues.
Important to avoid blame being discussed outside the investigation (ref: Warwick University research findings)

24. How to conduct an adapted NGT
Participants...
Generate a list of CDPs & SDPs using Change analysis
(True NGT = Generating a list of ideas by brainstorming/brainwriting)
Combine or eliminate duplicate ideas.
Individually vote on CDPs/SDPs considered most influential
Rank/prioritise CDPs & SDPs in line with votes cast

25. Group work (Cont) Combine similar issues into one CPD/SDP
Prioritise CDPs and SDPs for further analysis

26. Key Points – CDPs and SDPs
A really important bit!
Concentrate on correct phrasing of CDPs + SDPs
Allow carefully facilitated exploration of perceived blame issues - at this stage only