quality directions australia 20031 improving clinical risk management systems: root cause analysis

Quality Directions Australia 2003 1

Improving clinical risk management systems:

Root Cause Analysis


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


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



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



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


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)


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 assumptionThe date/ time and place of the event must

be clearly specified


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


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


The RCA Process

Understanding causes of variation: Use multiple investigators to minimise bias Examine relevant documents Conduct structured interviews Field observation

No solutions!!


The RCA Process

Select risk reduction strategiesDetermine which of the risks is most urgent

using a risk stratification toolDevelop a list of action items in terms of

urgencyUse a how/ how diagram to develop action

stepsDevelop evaluation measures for each of the

items


The RCA Process

Go through the PDCA cyclePlan the improvementDo the improvementCheck the effectiveness of the

improvementAct to hold the gain ( policies/

procedures/ education/ongoing evaluation)


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 membersPrepare for first team meetingGo through the processDisseminate the action plan


Using RCA for the case study

Describing the event As per case study – Transfer of

responsibility



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)



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


Flow charting

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?


Transfer of Responsibility

Equipment

Procedures People

Policies

Patient fall

Causes Effect

Fishbone Diagram


Transfer of responsibility

why did reception send man to ward?

no one to ask no contingency instructions not adequately trained

poor processes assumptions

no process

no/ inadequate policy lack of supervision

poor processes



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



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


Transfer of responsibility

How do we develop an appropriate transfer policy?

establish an appropriate team communicate with the taxi company

How do we do this?

identify person to communicate with

How do we do this?

identify all key players in the process

How do we do this?

flow chart the process

How do we do this?

P- Plan the improvement



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



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


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


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)


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


Keys to successful RCA

Selecting the right teamHaving a team with some knowledge of

the process- why/what/ howUsing a facilitator trained in the process,

tools and facilitation techniquesPractice the technique frequently to

maintain skills

quality directions australia 20031 improving clinical risk management systems: root cause analysis

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