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1 Root Cause Analysis Training for HCAI. 2 Session 1 Welcome and Introductions.

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Presentation on theme: "1 Root Cause Analysis Training for HCAI. 2 Session 1 Welcome and Introductions."— Presentation transcript:

1 1 Root Cause Analysis Training for HCAI

2 2 Session 1 Welcome and Introductions

3 3 RCA for HCAI Programme Session Timing (mins) 1Introduction15 2RCA – Context and Overview15 3RCA Process20 4RCA Tools25 Coffee10 5Role of the RCA Review Team25 6Analysis55 7Summary and Evaluation15

4 4 Session 2 RCA Setting it in context An introduction to RCA

5 5 RCA – Introduction & Context What is it? A retrospective review of a service user safety incident undertaken in order to identify what, how, and why it happened A 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.

6 6 RCA: Introduction and Context When should RCA be undertaken for HCAI?

7 7 When should RCA be undertaken for HCAI? All MRSA bacteraemia Local consideration to CDI cases that may include: –CDI Deaths –End stage disease e.g. colectomy –Outbreaks –Cluster Other infections as per local policy

8 8 Benefits of RCA for HCAI?

9 9 Benefits of RCA ? Service User Reduced risk of infection, increased safety and quality of care Improved service user choice Increased Public confidence Providers of Care Improved quality and safety, focus on risks and contributory factors, ability to target resources, improved service user pathways, increased service user confidence, shared learning Reduced length of stay Reduced litigation Improved staff moral Commissioners of care Improved assurance, governance, education, communication, clinical practice, shared learning Improved ability to commission quality care National Reduced infection rates, reduced political focus, development of tools and guidance, increased public confidence

10 10 Session 3 RCA Process

11 11 A Clear Process for HCAI React -Identify immediate care needs -Commence treatment and management of bacteraemia -Identify any obvious problems and take action Record -Gather data -Map the patients journey -Arrange RCA review meeting to identify problems, contributory factors and root causes -Agree action plan Respond -Deliver action plan -Monitor action plan delivery and impact -Identify & act upon organisational themes and trends

12 12 RCA for HCAI: Best Practice Process Organisations encouraged to perform gap analysis against process Aiming to embed HCAI prevention into everyday culture Guidelines intended as a benchmark for local interpretation and action to improve on their existing process rather than replace it

13 13 Process

14 14 Session 4 Root Cause Analysis Data Gathering Tools

15 15 MRSA Data Gathering Tool

16 16 How to use the tool RCA Lead completes the data gathering tool prior to the formal RCA review meeting The tool is sent to participants in advance of RCA review meeting RCA Lead maps the data to aid analysis at the review meeting

17 17 Session 5 Role of the RCA review team

18 18 Purpose of the RCA Review

19 19 Purpose of the RCA Review Analyse the data gathered Identify problems in the care pathway Identify contributory factors Identify root cause Identify actions to prevent recurrence

20 20 RCA Review Who should be involved ?

21 21 Who should be involved ? Core Team RCA Lead Executive lead DIPC Microbiologist / Infection Control Doctor Infection Control Practitioner Admin Support Risk/Performance Manager Matron / Senior Nurse Care setting representatives Doctor responsible for management of patient Nurse responsible for care of patient Others as appropriate

22 22 Develop an action plan Provide an expert contribution to the validation of the key issues/ emerging findings Make recommendations and agree actions that relate to the most fundamental cause(s) Learning the Lessons Communicate findings through local staff bulletins and team meetings Demonstrate leadership and recognition of the seriousness of HCAIs to all clinical staff Ensure outcomes and actions are implemented Escalate unresolved issues to management team Educate staff to ensure new practices are sustained Analyse the information Contribute to analysis of human and other contributory factors Analyse underlying systems and processes through a series of why questions Validate the data Review RCA paperwork in advance of meeting Contribute to the discussions to validate the information and data Challenge assumptions Roles and Responsibilities Of The RCA Review Team

23 23 Verifying the data RCA Lead checks the findings from the initial data collection exercise to ensure there are no gaps and all unconfirmed data has been confirmed RCA Lead presents the findings in a logical order to the group RCA team identifies the key issues/problems within the findings Using a process of brainstorming: –Capture initial thoughts of the team –Prioritise in order of importance Asking the right question is at the heart of effective RCA process –This will help to ensure you gather useful information and learn more

24 24 Identifying Problems Simple definition Something happened that should not have happened…… …..or something should have happened, but didnt.

25 25 Describing your problems To effectively analyse problems, a specific description of what happened is required: Be specific not vague: Communication failure = X Nurse failed to inform doctor of wound condition = OK Identify what happened not why: Inadequate training on hand hygiene = X SHO did not wash or decontaminate his hands = OK

26 26 Analysis of findings Once the problems have been identified the review team needs to: Analyse the key issues/problems Drill down to unearth the contributory factors and ultimately the root causes Reach agreement on the root cause Use tools such as Five Whys and the cause and effect diagrams to help explore the contributory factors of each problemFive Whys Tools are designed to encourage more in-depth analysis at each level of cause and effect

27 27 Five Whys Technique IP&C was not included in the induction training for new starters Why? Nurse failed to undertake MRSA screening on admission She was not aware this was a requirement for emergency admissions This was not covered in her orientation to the MAU Why? No Registered Provider wide approach to ward induction programmes Why? Root Cause Why?

28 28 Identify 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.

29 29 Confirming action plan and follow through Chair will lead the discussion on identifying actions to be undertaken to: –Address the root causes –Highlight the outputs of each action –Outline the timescales for delivery –Identify the responsible owner Decide what can be done to prevent the problem happening again Explore how the solution will be implemented Agree who will be responsible/accountable Agree what are the risks of implementing the solution

30 30 Session 6 Analysis

31 31 Analysis Who needs to be present at the review meeting ? Is there any data missing?

32 32 Participants at the review meeting? RCA Lead Consultant in charge of patient Matron/s Ward Managers Junior Doctors ICN Microbiologist Pharmacist Locality Manager District Nurse/s PCT Manager GP

33 33 Is there any data missing? Community screening policy A&E record Staff training records - PCT Staffing levels Process for blood culture taking Bed management data –side room use and time to isolation

34 34 Group Activity Discuss and Identify: Problems Risks to Other Patients Contributory Factors Root Causes

35 35 Findings – Pre Hospital ActivityIdentified Problems Long term management of catheterised patients No systematic review of care needs or referral for review No engagement of continence teams or urology links despite service user requests and ongoing catheter problems No detailed plan for long term supra pubic catheter care and type of catheter used No MRSA risk assessment undertaken MRSA screening was not carried out although service user was high risk – (previous admission to ICU in Spain).

36 36 Findings – Pre Hospital ActivityIdentified Problems Routine change of supra pubic catheter No plan of care for known difficult/traumatic supra pubic catheter change Sensitivities to catheter products not effectively communicated No antibiotic cover to reduce the risk of infection following traumatic catheterisation. Previous problems with haematurea.

37 37 Other factors – Pre Hospital ActivityContributory factors Documentation Poor legibility Lack of chronology and significant gaps in the records

38 38 Delayed diagnosis of MRSA – Hospital ActivityProblems to be addressed Screening Isolation Decolonisation Antibiotics No MRSA screening on admission despite high risk Delay despite diagnosis with MRSA Bacteraemia 18 hour delay in isolating service user (including multiple bed moves) No evidence of cohorting in the intervening period No evidence of ICN engagement 24 hour delay in commencement of decolonisation 24 hour delay in starting IV antibiotics Unclear prescriptions on drugs chart

39 39 RCA Review What are the root causes?

40 40 Session 7 Summary

41 41 RCA for HCAI Further Reading Towards Cleaner Hospitals and Lower Rates of Infection 7 Steps to service user Safety Anderson, 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 2007 Useful Websites:

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