1. Quality Directions Australia 20031 Improving clinical risk management systems: Root Cause Analysis

2. Quality Directions Australia 20032 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

3. Quality Directions Australia 20033 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

4. Quality Directions Australia 20034 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

5. Quality Directions Australia 20035 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

6. Quality Directions Australia 20036 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)

7. Quality Directions Australia 20037 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

8. Quality Directions Australia 20038 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

9. Quality Directions Australia 20039 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

10. Quality Directions Australia 200310 The RCA Process Understanding causes of variation:  Use multiple investigators to minimise bias  Examine relevant documents  Conduct structured interviews  Field observation No solutions!!

11. Quality Directions Australia 200311 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

12. Quality Directions Australia 200312 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)

13. Quality Directions Australia 200313 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

14. Quality Directions Australia 200314 Using RCA for the case study Describing the event As per case study – Transfer of responsibility

15. Quality Directions Australia 200315 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)

16. Quality Directions Australia 200316 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

17. Quality Directions Australia 200317 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?

18. Quality Directions Australia 200318 Transfer of Responsibility

19. Quality Directions Australia 200319 Transfer of responsibility why did reception send man to ward? no one to ask no/ inadequate policy lack of supervision poor processes no contingency instructions not adequately trained poor processes assumptions no process

20. Quality Directions Australia 200320 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

21. Quality Directions Australia 200321 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

22. Quality Directions Australia 200322 Transfer of responsibility How do we develop an appropriate transfer policy? establish an appropriate team How do we do this? identify all key players in the process How do we do this? flow chart the process communicate with the taxi company How do we do this? identify person to communicate with How do we do this? P- Plan the improvement

23. Quality Directions Australia 200323 Using RCA for the case study D-Institute the changes  ensure that staff are educated on the changes C- Check effectiveness of actions Carry out relevant audits to ensure this is working  make further changes if necessary

24. Quality Directions Australia 200324 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

25. Quality Directions Australia 200325 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

26. Quality Directions Australia 200326 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)

27. Quality Directions Australia 200327 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

28. Quality Directions Australia 200328 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