Why Root Cause Analysis is Performed Root Cause Analysis in Healthcare Part - 1 Prof (Col) Dr R N Basu Executive Director Academy of Hospital Administration Kolkata Chapter The goal of the root cause analysis is to produce an action plan The action plan identifies: The strategies the organization intends to implement to reduce the risk of similar events occurring in the future. Joint Commission International 1 2 The Relationships Between a Sentinel Event and Its Causes RCA in Healthcare Active failures, shown as the tip of the iceberg, reveal only the proximate causes of a sentinel event; latent conditions loom below the waterline, representing the underlying causes. JCI 1 3 Importance of RCA in Healthcare Institute of Medicine (USA) published a book in the year 2000 that had shaken thewhole world The title of the book is To Err Is Human This seminal book galvanized the whole world to take a serious note about patient safety The book highlighted that each year, in USA, 44000 to 98000 Americans suffer from medical errors 4 Many of these patients die This set the stage for new thinking about patient safety Patient Safety is the most important component of healthcare delivery Industry have been using RCA for improvement of quality of their products Healthcare borrowed the concept to improve quality and patient safety Veteran Administration (VA) created NCPS for specifically focusing on patient safety with RCA as a methodology 5 The IOM 2 recommended that accreditation bodies should support actions for patient safety The Joint Commission, in response to the IOM report, mandated focus on patient safety RCA is established as a methodology to analyze unintended variation of processes leading to adverse events Similarly, many other agencies took up RCA as a quality improvement tool. Some of them are: National Quality Forum, Department of Health and Human Services, Centre for Medicare and Medicaid Services 6 1
Definition of a Problem Root Cause Analysis addresses a problem The definitions of problem are: A question proposed for solution (Webster s Revised Unabridged Dictionary) A state of difficulty that needs to be resolved (Wordnet) How to Solve a Problem Every problem is triggered by some underlying cause(s) The two-stage approach that can be considered to solve a problem is: Identify the cause/(s) Find ways to eliminate these causes and prevent them from recuring On the face of it this looks very simple 7 8 Sometimes to find the underlying cause, it takes considerable effort This effort is usually underestimated Many all-knowing person may offer a quick off-the-cuff solution This may be a superficial level cause and not the one which lies at the bottom and triggers the chain of events Therefore, the importance of identifying them is enormous Once the true cause(s) are found, eliminating them is usually easy Patients, of course, would like that problem should not occur at all 9 Different Levels of Causes A problem may have many causes at different levels A lower level cause may give rise to an upper level cause and so on till the problem is visible Problems can be classified as nelow: Symptoms These are not the actual cause but as signs of a problem 10 First-level causes These are causes that directly lead to the problem Higher level causes These are causes that leads to the first level cause They do not directly cause the problem These causes a link in the chain of cause-and-effect relationships These cause-and-effect ultimately leads to the visible problem Some problems have multiple interlinked causes The first level causes are the Root Cause(s) The Nature of Variation Healthcare has hundreds of processes All processes are liable to variation due to various reasons Causes of variation: Common cause variation These are inherent in the process itself Common-cause variation is random variation present in stable healthcare processes. Special cause variation Special-cause variation is an unpredictable deviation resulting from a cause that is not an intrinsic part of a process. In healthcare the process owners should make all out effort to minimize process variation 11 12 2
Dealing with Variation If the special cause of variation is removed, the current problem may be solved It will not prevent the problem from recurring Example: If the call bell is not answered when the patient presses it, counseling the nurse may not prevent the same again A root cause analysis tries to expose the first level causes for the deviation in the process In the example of the nurse not responding to the call bell, the causes could be different: The census may be high There are more acute cases in the ward, or The nurse to patient ratio may be low Or, the causes may be further down Enough nurses are not available for recruitment Nurses are going abroad in large numbers They get much higher salary abroad Nurses are overburdened with many non-nursing jobs 13 14 The proximate causes (special causes) at the point of delivery is very easy to identify The nurse, in the example, may be blamed as callous or negligent or may be sleeping Contrary to the above, the root causes or the common causes are at the bottom of the problem It needs to be understood that: Any variation may be due to the interaction of both common and special causes One Root Cause may not be sufficient to cause variation in the process but may be combination of multiple root causes Root Cause Analysis 3 Definition No universally accepted definition It is described as: A process for identifying the basic or causal factors that underlie variation in performance. The analysis process ranges from one quality tool to the full range of quality improvement tools. Ideally, the analysis encompasses a wide range of methods and techniques 15 16 Tools and Approaches in RCA Tools that are used for RCA are of varying nature The purpose of the RCA process is to expose: A process or processes The potential causes of variation The changes that make variation less likely to recur in the future Usually, the RCA is used when a bad outcome has already occurred It can also be used for near misses The RCA process is completed when Solution to the variation is proposed, implemented, tested, verified and the transfer of knowledge is completed Person-Level Impediments to Effective RCAs Problem solving skill is not widespread in healthcare. There are several reasons: Administrators and Clinicians are not well trained in this skill beyond their clinical intuition They are asked to conduct thorough stepwise postmortem In addition, they are also asked to recommend a solution and test its effectiveness There is an ever-increasing pressure to report these incidences in order to reduce its consequences for the organisation 17 18 3
Solving Problems in a Blame Culture We all work in a blame culture We usually believe that the source of the problem is the person making the mistake System problem solving takes a different view This requires to think in terms of process rather than performance error. It is no denying that humans are fallible and mistakes may happen and also needs to be considered But the circumstances under which a person is compelled to commit a mistake is more important If the conclusion is that the person at whose hands the mistake happened ignoring the condition in which it occurred, the next mistake happening may not be prevented Human accountability cannot be ignored when mistakes happen The condition that create the climate for the incident to occur is at the root of the problem There are two approaches to human error Person approach Systems approach These two approaches needs to be understood for proper management of errors and their prevention in healthcare 19 20 Person Approach This approach is intuitive, long standing, judgmental and traditional In certain circumstances it may be commendable Blaming individuals is emotionally more satisfying People are viewed as free agents and they have the choice of chosing between safe and unsafe mode of behaviour 21 If something goes wrong, it seems obvious that an individual or group of individuals must have been responsible We immediately tend to blame an individual who is at the sharp end for the cause of the error Sharp end is the point at which the care is delivered This involves the nurses, the physicians, surgeons, anaesthetists, pharmacists and the like The view in this approach is that the unsafe act is occurring primarily from aberrant mental process These are: forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness 22 The remedial measures are directed mainly at reducing unwanted variability in human behaviour These measures include: Poster campaigns that appeal to peoples sense of fear Writing another procedure (or adding to existing ones) Disciplinary measures and even firing the individual Threat of litigation Retraining Naming, blaming and shaming Followers of this approach tend to treat errors as moral issues The proponents of this approach assume that bad things happen to bad people Psychologists call it just -world hypothesis System Approach The basic premise in this approach is that humans are fallible, and Errors can happen in the best of the organisation Errors are seen as consequences rather than causes Their origin is not in the deviation from normal and accepted norms of human behaviour Their origin is in the preceding system factors in which the work takes place 23 24 4
Remedial actions are based on the assumption that human condition may not be amenable to change but the condition under which the humans work can be changed All hazardous technologies have barriers and safeguards against errors When an adverse event occurs the important issue is not who blundered But the issue is how and why the defenses failed Practice-Level Impediments to Effect RCAs There are many problems with how RCA is commonly done: Often only one tool is used five whys There are multiple steps in doing RCA Trying to find the root separating from other steps faces many odds Attention is often focused to find the root cause without attempting to find solutions 25 26 Solution recommended by the RCA team is not tested by measuring the outcome And as a result no necessary adjustment are done Teams usually do not publicize their good work If done, would be beneficial to others who could apply the knowledge gained to their own situation A large proportion of organisation keep on repeating over and over the same RCA Repeating the same RCA loses its value, loses its seriousness and diminishes employee morale The RCA Process For conducting a root cause analysis, one needs to follow certain sequential steps The names of the steps and the detailed content may vary with the team conducting the RCA Basically the RCA process has a six step approach There are sub-steps within each of these steps 27 28 Cotd. The six main steps are: 1. Define the event, succinctly describing the event or deviation that triggered the RCA 2. Find causes, coming up with as broad a range of potential causes of the problem as possible 3. Find the root cause, zooming in on the main culprit 4. Find solution(s), coming up with ways to solve the problem and prevent the event from recurring 5. Take action, implementing the solution(s) and ensuring that things stay that way 6. Measure and assess, determining whether the solution(s) work and solve the problem 29 30 5
Purpose of Step 1: Define the Event The overall purpose of this step is to scope the problem This is starting point of the RCA This should be described clearly, concisely and without any ambiguity The success factors for this phase are: Reality to be described even the sensitive ones without being afraid No speculation about what caused the event Relevant team composition A multidisciplinary team to be composed with members having domain knowledge The team should include the person owning the process The team need not be too ambitious Time should allow sufficient debate to take place No blame should be placed on any one No guess work to be done to identify the culprit 31 32 The first step is fundamental Should be handled diligently Sometimes there is a tendency to skip steps Many of us believe that we know what the problem is and what is the solution Though may be true for simpler problem but it is always preferable to go systematically Investigators should remain calm, should not get emotionally involved and try to understanding the problem with a neutral frame of mind The Team A team that shall investigate the problem should be broad based with inclusion of all necessary skills It is quite often seen that the task of RCA is left to one individual or the team consists of a very small group of person However the team should not be so large that it becomes un-managable Members should be able to find meeting times 33 34 Substeps in Step 1: Define the Problem The sub-steps in this step are: Trigger the RCA process This means officially launch the RCA project Mandate and organise the RCA team This is necessary to provide them with necessary authority Plan the RCA project by defining the tasks to be performed Describe the event in detail This is a most demanding requirement 35 1A: Trigger The RCA Process The trigger could come from a number of different sources Internal triggers Can be from employees observing poor practice or someone having witnessed an event External triggers: Could be a patient, family members, visitors, or other stakeholders System triggers: Reviews, surveys, or audits Specific incidents: Patient fatalities, employee injuries, damage to equipment, or other events that exceed a certain limit 36 6
1B: Mandate and Organise the RCA Team A clear and concise mandate should be developed as per the organisational policy The mandate should define the team s authority, responsibility, and objectives Composition: Team leader who is quite knowledgable Facilitator experienced in conducting RCA and should be able to facilitate team s functioning Team members maximum six 1C: Plan the RCA Project The plan should encompass both external and internal expectation As per the Joint Commission, the external requirements are: Events should be self-reported within five days Acceptable RCA and action plan should be received within 45 days of the event The project plan can be displayed as a Gantt Chart 37 38 1D: Describe the Event in Detail The description at the minimum should include the following What is the event? When did it happen? Where did it happen? Who was involved? Has it happened before? If so how often? What were the consequences of the event? 39 40 7