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

2. 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.

3. 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

4. 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

5. 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.

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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.

14. 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?

15. 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

17. 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

18. IPRO CAUTI Fishbone

19. “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

20. “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

21. 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

22. 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!

23. 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

24. 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!

26. References
Rooney, J. J., & Heuvel, L. N. V. (2004). Root cause analysis for beginners. Quality progress, 37(7),
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_ _RCA_Toolkit_final.pdf

27. ? Questions? Thank you for your attention
I can be contacted at