All of the Regulatory and Accreditation agencies have some type of expectation for the conduct of Root Cause Analysis. It is inherent in our human nature to want to understand what happened, and it is what we need to have peace of mind. Our electric bill has increased by $50.00 – what happened? There was a car accident or house fire down the street – what happened? Something happened to a loved one at the hospital, urgent care center, or ambulatory surgery center – what happened?
To meet the regulatory and accreditation expectations, organizations and personnel that engage in the root cause analysis must have an ambitious commitment and deep understanding of the Root Cause Analysis philosophy, process, and expected outcomes.
What is Root Cause Analysis?
There are many organizations that define Root Cause Analysis. To this author, the definition that seems to be the most practical comes from the Agency for Healthcare Research and Quality. It is here that they advise that RCA is:
- a structured method used to analyze serious adverse events.
- designed to identify underlying problems that increase the likelihood of errors.
- designed to avoid focusing on mistakes by individuals.
- designed to identify both active errors (those that occur at the intersection of humans and complex systems AND latent errors, which are those hidden problems within healthcare systems that contribute to adverse events.
Organizations need to have a robust RCA process.
Many models are available for the conduct of the Root Cause Analysis, each having commonalities with the other. It is essential for each organization to not only conduct the RCA team meeting but to ensure that the pre-and post-RCA team events are completed.
Initial RCA models focused on the engagement of the persons involved or proximal to the actual event in the actual root cause analysis. Newer models have migrated away from the actual engagement of these people. Regardless of whether the people involved or proximal to the event are at the RCA meeting, it is essential to gather information from these people in a meaningful manner. Avoiding finger-pointing and intonations of blame is essential in order for the person(s)to feel comfortable and supported when discussing the event. It is also helpful to:
- Gather information from personnel, including the patient, family, visitors, and other staff in proximity to the event in a timely manner. This will help to ensure that the information gathered reflects each individual’s recollections and is not influenced by group thinking. Providing training for those people who will be engaged in interacting with the above persons is essential. Some organizations will provide these persons with a set of questions as a guide to ensure that questions are open-ended, non-accusatory, and non-opinionated.
- Ensure the emotional needs of the individual staff member(s) are considered. Depending on the actual event, having chaplain services and/or employee assistance advocates available can be helpful to the employee as they relive difficult events by recounting the details.
- Gathering information from involved and proximal people is essential to ensure there is as clear a picture as possible as to what occurred at the time of the event. Depending solely on the information captured on an incident report is insufficient to determine the root causes.
More Pre-RCA Work:
When the event undergoing RCA involves a patient, the medical record of the patient should be reviewed, not simply for information about the event, but for what other information may have been documented that could have influenced the event. Reviewing the care plan can help us to understand the interventions that were or should have been in place. Marrying this information with patient-specific information is essential. For instance, a commonly documented patient condition that should greatly influence our care planning processes is the presence of dementia or Alzheimer’s Disease which can require specialty assessment tools, heightened strategies, and enhanced patient education, among other considerations.
The RCA Review process:
Organizations must ensure they create the right environment when conducting an RCA Review. There is no event more important to an organization than an RCA Review, and it must be given the highest priority within each organization. Staff engaged in the actual event should always be given the option to attend the RCA Review. The facilitator of the RCA Review must keep the team focused on digging deeper and deeper until the Root Cause is identified. The most common approach to this deep digging is using the 5 Whys approach. The 5 Whys is, on the surface, a simple problem-solving technique designed to help get to the root of a problem. The Five Whys approach involves looking at a problem and drilling down by asking: "Why?" or "What caused this problem?" To ensure that the organization goes beyond the simple or active causes, a Why question is asked after each prior “Why” question up to 5 times to continue to push deeper into the cause of the event. This approach takes an organization from an active cause analysis finding such as “ The staff member failed to do” to the more latent analysis findings such as process failures that caused or set the human up to fail.
Once a root cause is identified, the organization must establish an impactful, meaningful corrective action plan. This is where most organizations fail. Oftentimes, organizational action plans will focus heavily on education and/or re-education on existing processes as the customary go-to solution. Consider this: If education is the solution to an existing process problem, wouldn’t most staff get it wrong due to errant education? Has the process itself been thoroughly examined for root cause failure points? Education and/or re-education could be a corrective action; however, the educational plan should be considered fully. For example, if education/ re-education on the organization’s Fall Prevention protocol is the solution, shouldn’t the improvement activities focus on the quality/content of the educational materials, the venue in which the education was delivered, and the post-education assessment of the staff’s ability to comprehend the educational materials?
The absolute hardest component of the RCA process is developing meaningful improvement plans. Achieving a truly effective and credible corrective action plan relies on bravely digging deep into the root causes and establishing a comprehensive response that reflects a thorough understanding of the issues to prevent a reccurrence. This makes the role of the facilitator even more important and more difficult. Applying the 5 Why’s approach to each suggested improvement activity, carefully examining processes for failure points, and considering corrective actions in their full context can help you uncover the best solutions for your organization.
Post RCA Work:
We wish we could tell you that each improvement plan developed and implemented solved everyone’s problems, but they do not. Once an organization has determined what its improvement plan will be, it is essential that the implementation plan be as robust as the RCA process. Failure to develop an implementation plan, timeline, assigned responsibilities, and plan to monitor the effectiveness of the improvement plan is essential. Utilizing your organization’s Performance Improvement (PI) methodology, such as Plan-Do-Check-Act (PDCA), will ensure your design is thorough and allow you to utilize this body of work as an organizational PI project.
In closing, the Root Cause Analysis work is difficult from every aspect. The process can be extremely emotional, tense, and time-consuming, but result in a lifesaving, team building and deeply rewarding endeavor. Keeping the benefits top-of-mind when you feel burdened by the body of work will help to energize your organization through this critical work and ultimately make care safer. That is when your RCA process is working.