1. Standard Cause Analysis Model Norton Healthcare
Kelly Johnson, DNP, RN, CPPS
November 2018

2. Background Rationale Significance
1 in 4 American families are affected by healthcare harm in the U.S.
As many as 16% of Americans will experience preventable healthcare harm
Between 100K and 400K Americans die each year from preventable healthcare harm
If ranked, patient safety events would be the 3rd leading cause of death in the US
A medication error affecting a child occurs every 8 minutes in the US
Problem has been known for 15+years; exists at international level- not specific to NHC.
(Denham et al., 2012; Macrae, 2008)

3. Why Here? Why Now?
Reaching for Zero strategic plan to eliminate preventable healthcare harm
Significant variation in process
Voice of customer revealed opportunities for improvement
Punitive feeling meetings
Not getting to real causes
Lack of accountability for actions/demonstration of real change
Repeat events
Made a commitment to improve via our Reaching for Zero strategic plan. This project is part of one of the major domains of Reaching for Zero on event management.

4. International Guidelines
System Analysis of Clinical Incidents: The London Protocol (2001)
WHO Draft Guidelines for Adverse Event Reporting & Learning Systems (2005)
Patient Safety Handbook, VA (2011)
Respectful Management of Serious Clinical Incidents, IHI (2011)
Serious Safety Events: Getting to Zero, ASHRM 2012
Optimizing RCA & Organizational Learning, HPI, LLC (2014)
RCA2: Root Cause Analysis & Actions to Prevent Harm, NPSF (2015)
Several set of guidelines; many very old but still had valid recommendations because organizations have been so slow to change.

5. RCA2 White Paper
More weight to most recent national guidelines. Were able to put most of these recommendations in place.

6. Graduated Approach Written into strategic plan over multiple years
Foundational work on root cause analyses:
DMAIC PI methodology
Lewin’s Change Theory
Team included people from pilot hospital as well as system for planned replication
Piloted for 90 days at largest hospital with specialized services
Staged replication throughout rest of healthcare system over several months
Control plan still in place
Current focus on other types of cause analysis
Pilot facility:
Norton Hospital was chosen because:
Size and opportunity to test changes quicker than small facilities
Leader engagement level in patient safety
Culturally ready for change

7. Cause Analysis Model Root cause analysis Apparent cause analysis
Aggregate analysis
Common cause analysis

8. Standard Root Cause Analysis Model
Planned team response including executive sponsor
Immediate response checklist
Meeting 1 with checklist
Investigation launched
Identification
Determine what, why & how
Meeting 2, cause analysis with flow chart timeline
Core team and peer representatives and subject matter experts
Analysis
Executive sponsor assigns review of literature/standards
Meeting 3 for action plan
Measures of effectiveness
Summary sheet for feedback and learning
Change

9. Standard Root Cause Analysis Model
Planned team response including executive sponsor
Immediate response checklist
Meeting 1 with checklist
Investigation launched
Identification

10. Standard Root Cause Analysis Model
Determine what, why & how
Meeting 2, cause analysis with flow chart timeline
Core team and peer representatives and subject matter experts
Analysis

11. Standard Root Cause Analysis Model
Executive sponsor assigns review of literature/standards
Meeting 3 for action plan
Measures of effectiveness
Summary sheet for feedback and learning
Change

12. Apparent Cause Analysis
Smaller, faster review
Conducted at unit/department with their leaders
May include people involved
Typical tools utilized:
Causal Factor Fishbone
Cause Analysis Interviewing Tips
Cause Analysis Probing Questions by Causal Factor
Event Timeline Flowsheet

13. Lessons Learned Stakeholder support was crucial
Organizational assessment and gap analysis was needed to know where to start and what level of change could be accepted
Critical to have investigation completed before analysis meeting
Leaders must be engaged in action item tracking and accountability

14. Current State Monitor RCA process through control plan
Extended education on ACA process
Trial of risk grading and aggregate ACA with pharmacy on no-harm medication errors
Common cause analysis with RCAs

15. References
Dearholt, S., & Dang, D. (2012). Johns Hopkins nursing evidence - based practice: Model and guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.
Denham et al., (2012). An NTSB for healthcare - learning from innovation: Debate and innovate or capitulate. Journal of Patient Safety, 8(1), 3-14.
Parker, J. (Ed.). (2015). Root cause analysis in healthcare: Tools and techniques (5th ed.). [Adobe Digital Edition]. Retrieved from
Macrae, C. (2008). Learning from patient safety incidents: Creating participative risk regulation in healthcare. Health, Risk & Society, 10(1):
Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management, 20,
Shirey, M. (2013). Strategic leadership for organizational change. Journal of Nursing Administration, 43,
*Full evidence table for project available separately