ROOT CAUSE ANALYSIS AND JUST CULTURE: A PRACTICAL APPLICATION TO DRIVE IMPROVEMENT

Sheila Yates, MPH, CPHQ

OBJECTIVES

Participants will gain an understanding of Just Culture as a framework to employ Root Cause Analysis (RCA) at their own sites

Participants will gain an understanding on RCA as a tool for evaluation of clinical and administrative quality issues

Participants will practice RCA using scenarios and be able to replicate use of the tools with their own teams

AGENDA

A Just Culture is Defined as :

A fair and consistent environment that fosters open

communication, transparency, voluntary error reporting,

information sharing and a willingness to do the right thing!

Just culture is about:

A fair and consistent environment, open communication and a focus on learning

Reviewing contributing factors then determining accountability

Creating systems that promote patient safety

Including human error factors and systems thinking

Cutting across all levels of staff

Reinforcing the roles of risk and continuous quality improvement

NAME/BLAME/SHAME CYCLEEmployee

takes action that

contributes to error

Employee is punished

Reduced trust as

employee view as

“scapegoat”

Employees become

silent (CYA) less

reporting

Management less aware

of conditions

Errors more likely

DETERMINING INDIVIDUAL VERSES SYSTEM ACCOUNTABILITY

•Deliberate Act Test: Did the employee intent the act or the outcome?

•Incapacity Test: Did the employee come to work impaired

•Compliance Test: Did the employee knowingly and unreasonably increase risk?

•Substitution Test: Would another similarly trained employee in the same situation act in a similar manner?

FINAL WORD

We are all human and humans are not perfect

No one should be punished for reporting an “honest” mistake

We can’t fix something if we don’t know it’s broken

We all own the responsibility for speaking up and reporting

Be willing to expose areas of weakness as much as areas of excellence

WHAT IS ROOT CAUSE ANALYSIS?

A problem-solving approach to identify the underlying causes of problems or events

The goal is to discover:

oWhat happened?

oWhy did it happen?

oWhat can be done to prevent recurrence?

The outcome is a structured plan to prevent future events

WHEN SHOULD YOU DO AN RCA?

Following a serious event

If a trend shows an increase in errors

To solve system issues

To improve customer service

THE RCA PROCESS

SETTING THE STAGE

Schedule RCA meeting as soon as possible so that memories are fresh

Clearly communicate the purpose of the meeting

Team should be those involved in the event

Establish ground rules:oAvoid blaming or finding fault

oCommit to finding solutions

TOOLS

Sequence of Events

Cause and Effect Diagrams

Contributing Factors

5 Whys

METHODS TO DETERMINE WHAT HAPPENED

Recreate the sequence of events and learn the basic facts by:

Investigative individual interviews

Chart or record audits

Group processing

CAUSE AND EFFECT DIAGRAMS

Cause and effect diagrams also called Ishikawa diagrams or more commonly called fishbone diagrams are used to map out the causes of a specific event

They are best used to identify and explore potential root causes in a detailed and graphic manner often in a group setting

They allow the team to see causes related to a process, procedure or system failure

CONTRIBUTING FACTORS CATEGORIES People : Staff

People: Patient

Communication

Environment

Equipment & Supplies

Policies & Procedures

Leadership Activities

5 WHYS

A method used to explore the underlying relationship of a problem by looking at the cause and effect.

Helpful when problems involve human factors and interactions

You may need one “why” or you may need six

FINAL REPORT AND ACTION PLAN

All action plans should identify specific action items, measures of effectiveness, the time frame and staff accountability.

The facilitator should commit to the time/date of when the final RCA summary will be sent to the team members for review.

The team should be thanked for taking the time to participate in this important process and often a brief a meeting evaluation tool is used to gather feedback on the overall process.

BEST PRACTICES

Do not include any patient identifying information on RCA notes

Be aware of any state specific requirements - check with your local counsel

Update policies based on event findings

Try on a more minor event first – get familiar with the tools

As the facilitator, it is your role to keep the pace moving, it is very easy to get side tracked.

ENGAGING LEADERSHIP

Provide overview on the benefits of the RCA process and implementation a Just Culture program

Discuss what is currently happening and preventative strategies

Inform them upon RCA completion

Discuss the team’s action plan

Ask them how they would like to be involved

GROUP ACTIVITY

Break into groups of 4-5

Using Fishbone template and Contributing Factors handouts, choose one of the scenarios (or one of your own) to practice filling in the Fishbone template

Time: 15 minutes

A CHALLENGE TO YOU

Integrate Just Culture into your policies and procedures

Reinforce the importance of reporting incidents and learning from mistakes

Build trust and reinforce the importance of inquiry and RCA’s

Provide trainings on Just Culture and RCA tools