Presentation on theme: "Root Cause Analysis Training for HCAI"— Presentation transcript:
1Root Cause Analysis Training for HCAI IntroductionHouse keepingScene settingReview of competencies that should be achieved by end of sessionParticipants to complete competency self assessment sheet
2Welcome and Introductions Session 1Welcome and IntroductionsIntroductionHouse keepingScene settingReview of competencies that should be achieved by end of sessionParticipants to complete competency self assessment sheet
3RCA for HCAI Programme Timing Session (mins) 1 Introduction 15 2 RCA – Context and Overview3RCA Process204RCA Tools25Coffee105Role of the RCA Review Team6Analysis557Summary and EvaluationReview of AgendaExplain about working whilst having coffee
4RCA Setting it in context Session 2RCA Setting it in contextAn introduction to RCA
5RCA – Introduction & Context What is it?A retrospective review of a service user safety incident undertaken in order to identify what, how, and why it happenedA process of investigation and analysis is then used to identify areas for improvement.Finally recommendations and sustainable solutions are agreed to minimise the recurrence of the incident type in the future.ADDITIONAL INFORMATION TO USE TO TALK AROUND THE SLIDERCA is not new and has been part of the risk management process for many years – particularly in the investigation of serious untoward incidents.The use of RCA in the investigation of severe infection – has been promoted as good practice and many organisations have learnt from this processThe first HCAI tool was launched by the NPSA, this has been developed further and the revised tool will be used in today’s session.Reasons for using RCA for HCAI investigation:We have to move away from the notion that infection is a risk or by product of healthcare – patients should not be subject to the additional burden of infection if it is avoidable.If we understand what caused or contributed to infection during the course of the patients journey we can focus action and reduce risk.Emphasise this is not about the who but about the learning
6RCA: Introduction and Context When should RCAbe undertaken for HCAI?Invite comments from the group
7When should RCA be undertaken for HCAI? All MRSA bacteraemiaLocal consideration to CDI cases that may include:CDI DeathsEnd stage disease e.g. colectomyOutbreaksClusterOther infections as per local policyEnsure you understand the local context for RCA in the organisation (s) where your participants are from and their current practice and whether there are any other scenarios which could be used as examplesAll MRSA bacteraemias - pre and post 48 hour cases.Part of today’s challenge will be to consider how health economies can work together to understand and analyse the whole service user journey and jointly establish mechanisms to reduce infection risks.Relevant CDI CasesThe expectation to undertake RCA for these patients may differ between organisations and SHA’s. A number of organisations have found great benefit in undertaking RCA on CDI cases. It is generally suggested that RCA should be completed for all cases where it is included on the death certificate and colectomies.Other InfectionsWe are in a changing world and the focus on organisms will change as prevalence does. The principles of RCA are relevant for the review of other organisms besides MRSA and CDI.
8Benefits of RCA for HCAI? Invite comments from the group
9Benefits of RCA ? Service User Providers of Care Commissioners of care Reduced risk of infection, increased safety and quality of careImproved service user choiceIncreased Public confidenceProviders of CareImproved quality and safety, focus on risks and contributory factors, ability to target resources, improved service user pathways, increased service user confidence, shared learningReduced length of stayReduced litigationImproved staff moralCommissioners of careImproved assurance, governance, education, communication, clinical practice, shared learningImproved ability to commission quality careNationalReduced infection rates, reduced political focus, development of tools and guidance,increased public confidenceRoot Cause Analysis is very interesting but is ineffective unless it is done thoroughly and the information used, i.e. avoid ticking the box and then missing the point.Get groups to discuss and write down on post-it notes the benefits or effects RCA can bring to:PatientsRegistered ProvidersCommissioners / SHANationallyGet the group to feedback on individual topic areasUse the slide as prompts and suggestionsFacts rather than assumptions
11A Clear Process for HCAI ReactIdentify immediate care needsCommence treatment and management of bacteraemiaIdentify any obvious problems and take actionRecordGather dataMap the patient’s journeyArrange RCA review meeting to identify problems, contributory factors and root causesAgree action planRespondDeliver action planMonitor action plan delivery and impactIdentify & act upon organisational themes and trendsWe have discussed RCA and why it should be undertaken – but what does it actually entail?A clear process – to avoid ticking the box and missing the point.Try and give some examples from practice about what each stage involves. You are better to draw on your own experience for this, though the following may be usefulWhat does ‘react’ involve? An example form practice:Does the service user have a cannula insitu that has been there longer than the recommended hrs. If so, get it removed and then ask questions - is this just a one off, or is it poor practice across the care environment; are there other cannulas that have been left in longer than the recommended time? If so what actions need to happen straight away to improve practice to prevent other service users developing cannula related bacteraemia.Is the service user isolated. Have other service users in immediate vicinity been put at risk if not, and do they need screening? Are other patients MRSA positive in the vicinity of this service user indicating a transmission problem that needs to be addressed?
12RCA for HCAI: Best Practice Process Organisations encouraged to perform gap analysis against processAiming to embed HCAI prevention into everyday cultureGuidelines intended as a benchmark for local interpretation and action to improve on their existing process rather than replace itRead through the slide and ensure everyone understands the contentAnecdotally, the quality of the RCA is currently varied and inconsistent and true root causes are not always identified. We want to improve the quality of RCA and ultimately reduce the incidence of HCAI by implementing improvements which are identified by the RCA.
14Root Cause Analysis Data Gathering Tools Session 4Root Cause Analysis Data Gathering Tools
15MRSA Data Gathering Tool ADDITIONAL INFORMATION TO TALK AROUND SLIDEThis tool will help the data gathering process by giving a list of prompts pertinent/specific to MRSA. It will highlight from where information should be collected.This data gathering tool will help identify key issues /problems in the service user care pathway that may have contributed to MRSA bacteraemia.The review meeting members can then be informed of the key issues.This tool is not meant to replace an existing documentation– but could be incorporated or inserted – and included as part of the record of the RCA investigation.There is also a CDI version with slightly different questions for this infection.It is useful to give a practice example from your experience where an RCA investigation has missed a key issue. The following is an example:An ITU service user developed a bacteraemia and the RCA investigation concluded that the service user had self contaminated herself via central line route because she was agitated. What the RCA team lacked was information that the service user had been screened according to policy on admission and was negative. There was also another service user in the unit who was known to be MRSA positive in the vicinity of the service user who developed the bacteraemia. The true root cause was actually one of cross contamination by staff. Other information that would have been useful to the team would have been the hand hygiene audit scores at the time of the bacteraemia, which may have indicated which group of staff to target, or if audit scores were high, may have even indicated that it was not their own staff but occasional visiting staff that caused the contamination.
16How to use the toolRCA Lead completes the data gathering tool prior to the formal RCA review meetingThe tool is sent to participants in advance of RCA review meetingRCA Lead maps the data to aid analysis at the review meetingTalk through the steps on the slide.Stress that their role as an RCA review team member would be to review information gathered in preparation for the meeting, and consider what questions and issues they want to raise.As a member of the RCA team you maybe asked to collect some of the data.In addition, the tool also contains a summary sheet, (found at the back of the tools), for the RCA Lead to complete. Once done, the form is copied and sent to the review team in advance of the meeting so they have a chance to review the findings prior to the meeting.To assist the analysis process at the RCA review meeting the RCA Lead will need to map the information into a logical order prior to presenting, using one of the methods described earlier.
17Role of the RCA review team Session 5Role of the RCA review team
18Purpose of the RCA Review Use this slide to introduce what they think the role of team should be.It is definitely not about apportioning blame. Reiterate RCA is about findings out the what, why and how and then making improvements to prevent a reoccurrence.
19Purpose of the RCA Review Analyse the data gatheredIdentify problems in the care pathwayIdentify contributory factorsIdentify root causeIdentify actions to prevent recurrenceTalk through the slideIt is important to stress here that there is a lot to get through at this meeting and therefore the chair for the meeting needs to be focused and objective to ensure this agenda is covered within the timescale set for the meeting. The meeting may only last one hour.The issue of recurrence:If you only fix the symptoms, i.e. what you see on the surface, the problem will almost certainly happen again. This will lead you to fix it, again, and again, and again.If, instead, you look deeper to determine why the problem is occurring, you can fix the underlying systems and processes that cause the problem – to do this you need to ask ‘why’?
20RCA Review Who should be involved ? Ask participants to call out answers to the question
21Who should be involved ? Core Team Care setting representatives RCA LeadExecutive leadDIPCMicrobiologist / Infection Control DoctorInfection Control PractitionerAdmin SupportRisk/Performance ManagerMatron / Senior NurseCare setting representativesDoctor responsible for management of patientNurse responsible for care of patientOthers as appropriateAnalyse a situation fully before looking at factors that contributed to the problem.People who are most familiar with the problem can help lead to a better understanding of the issues.The required composition of the review team will vary depending on the case. All team members need to have a valid reason for being present, i.e. because of their expert knowledge, or personal involvement, or level of authority to action improvements.The Chair of the RCA meeting should be objective and focused and will determine who needs to be present to get the best outcome. They also need to have a level of authority that will ensure actions will be implemented.The meeting needs to be well facilitated.Ask the group to consider who the RCA Lead is likely to be in their own organisation
22Analyse the information Roles and Responsibilities Validate the dataReview RCA paperwork in advance of meetingContribute to the discussions to validate the information and dataChallenge assumptionsAnalyse the informationContribute to analysis of human and other contributory factorsAnalyse underlying systems and processes through a series of ‘why’ questionsRoles and ResponsibilitiesOfThe RCA Review TeamDevelop an action planProvide an ‘expert’ contribution to the validation of the key issues/ emerging findingsMake recommendations and agree actions that relate to the most fundamental cause(s)Learning the LessonsCommunicate findings through local staff bulletins and team meetingsDemonstrate leadership and recognition of the seriousness of HCAIs to all clinical staffEnsure outcomes and actions are implementedEscalate unresolved issues to management teamEducate staff to ensure new practices are sustainedUseful toolsValidating the data –Use timelines to present findingsDrill downAnalyse Information5 whysFishbone diagramsDevelop Action PlanAction plan templatePDSALearning LessonsStaff bulletins and team meetingsIntranet alert noticesScreen saversShare learning across SHA’sEmphasise that documentation needs to be available in a clear and concise way
23Verifying the dataRCA Lead checks the findings from the initial data collection exercise to ensure there are no gaps and all unconfirmed data has been confirmedRCA Lead presents the findings in a logical order to the groupRCA team identifies the key issues/problems within the findingsUsing a process of brainstorming:Capture initial thoughts of the teamPrioritise in order of importanceAsking the right question is at the heart of effective RCA processThis will help to ensure you gather useful information and learn moreThe RCA lead will undertake the data verification and present the findings in a logical order.Stress that all information needs to be present and any unconfirmed findings e.g. hearsay, need to be verified, before the identification of the problem can begin and analysis takes place. Remind the group that they can only analyse the facts.The review team will use brainstorm techniques to identify the problems associated with this MRSA/CDI investigation. This needs to be done before you can ask the question ‘why’ to get to the root cause.
24Identifying Problems Simple definition Something happened that should not have happened………..or something should have happened, but didn’t.Identify two types of problems, those associated with direct care provision and those associated with service provision.Background info on types of problems:Care Delivery Problems = problems associated with direct care provision e.g. Venflon secured with elastoplast, so Venflon site is not visible or, Pyrexia not investigated, screening and decolonisation not carried out in line with guidelines.Service Delivery Problems = problems associated with service provision, e.g. supplies of alcohol gel unreliable, or induction training only attended by minority of newly recruited staff – unavailability of isolation facilities. Medical staff not available to prescribe prophylactic antibiotics.Use techniques such as:BrainstormingBrain writing
25Describing your problems To effectively analyse problems, a specific description of what happened is required:Be specific not vague:Communication failure = XNurse failed to inform doctor of wound condition = OKIdentify what happened not why:Inadequate training on hand hygiene = XSHO did not wash or decontaminate his hands = OKThis slide gives examples of care delivery problems. It is important to remember to be specific at this stage otherwise contributory factors that influenced the occurrence of this problem will not be clearly identified.Point out that when individuals are undertaking an RCA they are often concerned at this stage that an individual is clearly associated with the problem identified. But this is not the end of the analysis.The next step involves asking the question why.E.g. why did the nurse fail to inform the doctor of the wound condition? Answers to this will identify the contributory factors.
26Analysis of findingsOnce the problems have been identified the review team needs to:Analyse the key issues/problemsDrill down to unearth the contributory factors and ultimately the root causesReach agreement on the root causeUse tools such as ‘Five Whys’ and the cause and effect diagrams to help explore the contributory factors of each problemTools are designed to encourage more in-depth analysis at each level of cause and effectFurther info on the ‘Five Whys’ tool can be found on the NPSA website and a hand out on this is available at the end of the training to take away.‘Five Whys’ works very well on simple problems. If the problem is more complex you may need to use other techniques, e.g.; fishbone diagram and contributory factors list.A structured process will make sure better information is gathered and more is learnt and understood.
27‘Five Whys’ TechniqueNurse failed toundertake MRSAscreening on admissionWhy?She was not aware this was a requirement for emergency admissionsWhy?This was not covered in her orientation to the MAUWhy?IP&C was not included in the induction training for new startersWhy?No Registered Provider wide approach to ward induction programmesThe ‘Five Whys’ is a simple problem-solving technique allowing users to get to the root of the problem quickly.It involves looking at any problem and asking:"Why?"and"What caused this problem?“The slide contains an example of the ‘Five Whys’ analysis - an effective problem-solving technique.Talk through the example explaining it is fictious, before anyone argues the answers to the ‘whys’. Also state that the question ’why’ is asked until you can go no further with it. In this case it was asked four times. The number of times is irrelevant even though it is called 5 whys.Root Cause
28Identify Root Cause(s) What is a Root Cause?A fundamental contributory factor which, if resolved, will reduce the likelihood of recurrence of the identified problem.There may be more than one root cause and therefore the RCA team must identify the contributory factors which have the greatest impact on each problem.Using the ‘Five whys’ technique will help identify the most significant contributory factors.Discuss the content on the slide.Stress there is rarely only one root cause.
29Confirming action plan and follow through Chair will lead the discussion on identifying actions to be undertaken to:Address the root causesHighlight the outputs of each actionOutline the timescales for deliveryIdentify the responsible ownerDecide what can be done to prevent the problem happening againExplore how the solution will be implementedAgree who will be responsible/accountableAgree what are the risks of implementing the solutionThe final part of the review meeting is used to:Agree actions to address the identified root cause(s).An important stage in the process is to ensure necessary changes will be:OwnedActionedEmbedded in the organisation to reduce reoccurrenceOutcomes are identifiedProcess for measurement of outcomes is identified – defined metricsMonitoring arrangements are identified
30Session 6AnalysisWhilst the case study is from an acute perspective it incorporates a whole patient journey. You may choose to use this example or develop your own.Remind people of the case study summary that was on the table as they arrived and ask who managed to read it through.Clarify that this session uses a case study to look at:AnalysisIdentification of causalityIdentification of contributor factors and actionDelivery planningOne each table there are sets of completed data sheets. Additional information can be added to the sheets if it is felt this is required.Introduce the file in the centre of the table all the detailed care records and available documentation for service user A.
31Analysis Who needs to be present at the review meeting ? Is there any data missing?Ask the group to take 5 minutes to consider who you would invite to a review meeting.Secondly ask if there is any information or data missing that they would like to see.Get them to call out & list this on the flip charts
32Participants at the review meeting? RCA LeadConsultant in charge of patientMatron/sWard ManagersJunior DoctorsICNMicrobiologistPharmacistLocality ManagerDistrict Nurse/sPCT ManagerGPCollect feedback from the groups. Ask them to think of ways to include carers in the RCA process.Secondly show this slide as an an example .Compare and contrast with group findings.May not always be able to get everyone in one room to discuss the RCA and will need to think creatively about how input is obtained, e.g.; conference callsNeed to be aware of striking the balance between the availability of data and the need for people to attend the RCA meeting.Ask how often PCT staff are involved in review meetings?
33Is there any data missing? Community screening policyA&E recordStaff training records - PCTStaffing levelsProcess for blood culture takingBed management dataside room use and time to isolationCollect feedback from the groups first and then show this slide as an example.Compare and contrast with the group findings.If it is not possible to collect information about the environment and other organisational issues then this should be recorded on the RCA form. In addition if information is not relevant then this should also be recorded so that the RCA form is complete.
34Group Activity Discuss and Identify: Problems Risks to Other Patients Contributory FactorsRoot Causes
35Findings – Pre Hospital ActivityIdentified ProblemsLong term management of catheterised patientsNo systematic review of care needs or referral for reviewNo engagement of continence teams or urology links despite service user requests and ongoing catheter problemsNo detailed plan for long term supra pubic catheter care and type of catheter usedNo MRSA risk assessment undertakenMRSA screening was not carried out although service user was high risk – (previous admission to ICU in Spain).E.g. No MRSA risk assessmentWhy?Staff unaware of needsNo recent updating of infection, prevention and control trainingPolicies didn’t indicate need for trainingPolicies out of date – Root CauseE.g. No engagement of continence or urology teamsNo detailed care pathway established to include all relevant partiesNo multidisciplinary approach to careNo policy or protocol indicating best practice = Root Cause
36Findings – Pre Hospital ActivityIdentified ProblemsRoutine change of supra pubic catheterNo plan of care for known difficult/traumatic supra pubic catheter changeSensitivities to catheter products not effectively communicatedNo antibiotic cover to reduce the risk of infection following traumatic catheterisation. Previous problems with haematurea.E.g. No plan of care for know difficult/traumatic supra pubic catheter changeWhy?No plan of care for known difficult supra pubic catheter patientNurse was not aware of the need to inform the multi-displicianry teamNot part of current training programme. Training programme not updated for over 3 yearsTraining programme not undated for over 3 yearsThe policy for catheter care was out datedPolicy for catheter care (which includes staff training) is outdated = Root Cause
37Other factors – Pre Hospital ActivityContributory factorsDocumentationPoor legibilityLack of chronology and significant gaps in the recordsThere will be other findings from the analysis regarding general aspects of care that must also be addressed.Collect feedback from the groupsUse this slide as an exampleCompare and contrast with the group findings
38Delayed diagnosis of MRSA – Hospital ActivityProblems to be addressedScreeningIsolationDecolonisationAntibioticsNo MRSA screening on admission despite high riskDelay despite diagnosis with MRSA Bacteraemia18 hour delay in isolating service user (including multiple bed moves)No evidence of cohorting in the intervening periodNo evidence of ICN engagement24 hour delay in commencement of decolonisation24 hour delay in starting IV antibioticsUnclear prescriptions on drugs chartYou would need to understand ‘why’ for all of these highlighted problems/issues, even though they are not the root causes to the service user getting the MRSA infection.These are practice issues/causes for possible spread of infection to other patients in hospital and therefore need to be addressed in the action plan.
39What are the root causes? RCA ReviewWhat are the root causes?Problems – Explain- 8 pre hospital – ask ‘why’ for each to establish the root cause- 8 post hospital – ask ‘why’ to establish failures in the management systemsRoot CauseLack of integrated care pathway of catheter management
41RCA for HCAI Further Reading Towards Cleaner Hospitals and Lower Rates of Infection7 Steps to service user SafetyAnderson, Bjorn & Fagerhaug, et al (2000) Root Cause Analysis Simplified Tools 7 Techniques ASQ Quality Press.National Confidential Study of Deaths Following Meticillin-Resistant Staphylococcus aureus Infection. London: Health Protection Agency, November 2007Useful Websites:Explain there are no certificates of attendance as it does not provide evidence of learning.Suggest pre & post training event competency assessment will provide excellent source of Evidence for professional portfolios.The areas where participants have still not achieved high scores are the areas were they should focus their own personal development. Further reading and websites will direct them to information they require.Remind participants that principles they have learnt today have wider application beyond HCAI RCA and will help them in every day incident and complaints investigation.Stress value of on line learning package of NPSA website to build on what they have learnt today.