Improving clinical risk management systems: Root Cause Analysis

1. Improving clinical risk management systems: Root Cause Analysis Quality Directions Australia 2003

2. Investigating adverse events • What often happens when we carry out these investigations: • Inconsistent approaches • Done by management • All issues not explored • Focuses on who did it rather than what went wrong • Incomplete solutions • No organisational learning Quality Directions Australia 2003

3. Getting to the root cause • Arriving at the right answer is dependent on: • Asking the right questions • Asking the right people • Asking in the right way • Using the right time frame Quality Directions Australia 2003

4. Getting to the root cause • A structured systems approach ensures: • You are clear about the problem or event • The people involved in the problem/event are part of the process • All steps in the process are carried out in the right order • Actions are put in place and evaluated Quality Directions Australia 2003

5. Getting to the root cause Root Cause Analysis (RCA) is: • A structured approach aimed at getting to the root cause of a sentinel (adverse) event, with the right people, using a specified process and leading to the outcome of an achievable risk reduction plan • Used to uncover failures of systems design Quality Directions Australia 2003

6. The RCA Process • Describe the event • Organise the RCA team • Clarify the process leading to the adverse event • Understand the causes of variation • Select risk reduction strategies • Go through the PDCA cycle (Plan/Do/Check/ Act) Quality Directions Australia 2003

7. The RCA Process Describe the adverse event: • The event needs to be very clearly described with no emotive terms- as a statement of the facts • Watch for elements of bias or assumption • The date/ time and place of the event must be clearly specified Quality Directions Australia 2003

8. The RCA Process Organise the team: • RCA must be carried out by an appropriate team • Team members should include all of those involved in the event • Team members should include people able to authorise change • The process must be clarified with the team at the outset and appropriate ground rules set • An external person can be useful to challenge assumptions/ biases Quality Directions Australia 2003

9. The RCA Process Clarify understanding of the event: • Includes process and causes of variation • Tools should be used to assist in clarification • Useful tools are: • Flowcharting to record the sequence of events • Cause and effect diagrams to elucidate all contributory factors • Why/why and to dig down to root causes • Affinity diagramming to categorise factors Quality Directions Australia 2003

10. The RCA Process • Understanding causes of variation: • Use multiple investigators to minimise bias • Examine relevant documents • Conduct structured interviews • Field observation • No solutions!! Quality Directions Australia 2003

11. The RCA Process Select risk reduction strategies • Determine which of the risks is most urgent using a risk stratification tool • Develop a list of action items in terms of urgency • Use a how/ how diagram to develop action steps • Develop evaluation measures for each of the items Quality Directions Australia 2003

12. The RCA Process Go through the PDCA cycle • Plan the improvement • Do the improvement • Check the effectiveness of the improvement • Act to hold the gain ( policies/ procedures/ education/ongoing evaluation) Quality Directions Australia 2003

13. Preparation for RCA • Have a group of staff trained in the process • Notify all relevant staff ASAP after a sentinel event has occurred • Appoint RCA team members • Prepare for first team meeting • Go through the process • Disseminate the action plan Quality Directions Australia 2003

14. Using RCA for the case study • Describing the event • As per case study – Transfer of responsibility Quality Directions Australia 2003

15. Using RCA for the case study • Organising the team • DON or DMS of Hospital a to chair • ADON A • ADON B • Receptionist Manager • Clinical Risk Manager A to facilitate • (Taxi driver) Quality Directions Australia 2003

16. Using RCA for the case study • Clarifying the process • Flow charting • Decision to transfer A to B/ communication with Hospital B/ booking for transfer accepted by ADON B with delivery to ED/ taxi booked by Hospital A/ Verbal instructions for driver/ patient delivered to reception at Hospital B/ receptionist confirms patient expected/ patient directed to ward / patient and taxi driver walk to ward/ patient falls at ward entrance and fractures hip Quality Directions Australia 2003

17. Decision to transfer Communication with hospital B Booking accepted by ADON B Patient delivery to ED organised Taxi booked by hospital A How did communication occur? Was communication between appropriate people? How was transfer assessed? Does a written procedure exist? What instructions were given? Why was patient to go to ED? Is a taxi transfer appropriate? What information was provided to the driver? Flow charting Quality Directions Australia 2003

18. Transfer of Responsibility Quality Directions Australia 2003

19. Transfer of responsibility Quality Directions Australia 2003

20. Using RCA for the case study • Understanding the causes of variation • Communication between Hospital A and B • Communication between Hospital A and taxi service • Reception processes at Hospital B • Admission policies at Hospital B Quality Directions Australia 2003

21. Using RCA for the case study • Selecting risk reduction strategies • Development of transfer policies between Hospitals A and B ( to include use of taxis) • Development of admission policies at Hospital B • Education of reception staff at Hospital B Quality Directions Australia 2003

22. Transfer of responsibility P- Plan the improvement Quality Directions Australia 2003

23. Using RCA for the case study • D-Institute the changes • ensure that staff are educated on the changes • C- Check effectiveness of actionsCarry out relevant audits to ensure this is working • make further changes if necessary Quality Directions Australia 2003

24. Using RCA for the case study • A- Act to hold the gain • Promulgate the new procedures • Continue to educate staff • Evaluate at regular intervals • Go through the PDCA cycle again if necessary Quality Directions Australia 2003

25. Limitations of RCA • Impossible to know if the root cause established by the analysis is the actual cause of the incident • May be tainted by hindsight bias • May be bias relating to prevailing concerns in the organisation • Time consuming and labour intensive • Qualitative rather than quantitative Quality Directions Australia 2003

26. When to use RCA • Needs to be used where there are systems issues and where the establishment of barriers is likely to prevent such errors recurring • When assessing the adverse event, need to identify if there are a number of things that went wrong as distinct from the proximal cause • Need to determine if prevention of the event occurring could have happened at many stages in the process, not just one poor action • Need to be able to distinguish between clinical complexity (difficult to control) and systems complexity (controllable) Quality Directions Australia 2003

27. Use of RCA • In the USA where RCA has been used consistently in the VHA for 10 months: • Events reported have increased by 30 times • Near misses reported have increased by 900 times • Near misses make up over 90% of events reported Quality Directions Australia 2003

28. Keys to successful RCA • Selecting the right team • Having a team with some knowledge of the process- why/what/ how • Using a facilitator trained in the process, tools and facilitation techniques • Practice the technique frequently to maintain skills Quality Directions Australia 2003