Root Cause Analysis Training for HCAI Introduction House keeping Scene setting Review of competencies that should be achieved by end of session Participants to complete competency self assessment sheet

Welcome and Introductions Session 1 Welcome and Introductions Introduction House keeping Scene setting Review of competencies that should be achieved by end of session Participants to complete competency self assessment sheet

RCA for HCAI Programme Timing Session (mins) 1 Introduction 15 2 RCA – Context and Overview 3 RCA Process 20 4 RCA Tools 25 Coffee 10 5 Role of the RCA Review Team 6 Analysis 55 7 Summary and Evaluation Review of Agenda Explain about working whilst having coffee

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

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. ADDITIONAL INFORMATION TO USE TO TALK AROUND THE SLIDE RCA 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 process The 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

RCA: Introduction and Context When should RCA be undertaken for HCAI? Invite comments from the group

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 Ensure 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 examples All 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 Cases The 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 Infections We 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.

Benefits of RCA for HCAI? Invite comments from the group

Benefits of RCA ? Service User Providers of Care Commissioners of care 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 Root 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: Patients Registered Providers Commissioners / SHA Nationally Get the group to feedback on individual topic areas Use the slide as prompts and suggestions Facts rather than assumptions

Session 3 RCA Process

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 patient’s 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 We 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 useful What does ‘react’ involve? An example form practice: Does the service user have a cannula insitu that has been there longer than the recommended 72-96 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?

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 Read through the slide and ensure everyone understands the content Anecdotally, 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.

Process

Root Cause Analysis Data Gathering Tools Session 4 Root Cause Analysis Data Gathering Tools

MRSA Data Gathering Tool ADDITIONAL INFORMATION TO TALK AROUND SLIDE This 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.

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 Talk 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.

Role of the RCA review team Session 5 Role of the RCA review team

Purpose 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.

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 Talk through the slide It 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’?

RCA Review Who should be involved ? Ask participants to call out answers to the question

Who should be involved ? Core Team Care setting representatives 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 Analyse 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

Analyse the information Roles and Responsibilities Validate the data Review RCA paperwork in advance of meeting Contribute to the discussions to validate the information and data Challenge assumptions Analyse the information Contribute to analysis of human and other contributory factors Analyse underlying systems and processes through a series of ‘why’ questions Roles and Responsibilities Of The RCA Review Team 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 Useful tools Validating the data – Use timelines to present findings Drill down Analyse Information 5 whys Fishbone diagrams Develop Action Plan Action plan template PDSA Learning Lessons Staff bulletins and team meetings Intranet alert notices Screen savers Share learning across SHA’s Emphasise that documentation needs to be available in a clear and concise way

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 The 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.

Identifying 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: Brainstorming Brain writing

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 This 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.

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 problem Tools are designed to encourage more in-depth analysis at each level of cause and effect Further 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.

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

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. Discuss the content on the slide. Stress there is rarely only one root cause.

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 The 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: Owned Actioned Embedded in the organisation to reduce reoccurrence Outcomes are identified Process for measurement of outcomes is identified – defined metrics Monitoring arrangements are identified

Session 6 Analysis Whilst 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: Analysis Identification of causality Identification of contributor factors and action Delivery planning One 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.

Analysis 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

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 Collect 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 calls Need 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?

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 Collect 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.

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

Findings – Pre Hospital Activity Identified 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). E.g. No MRSA risk assessment Why? Staff unaware of needs No recent updating of infection, prevention and control training Policies didn’t indicate need for training Policies out of date – Root Cause E.g. No engagement of continence or urology teams No detailed care pathway established to include all relevant parties No multidisciplinary approach to care No policy or protocol indicating best practice = Root Cause

Findings – Pre Hospital Activity Identified 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. E.g. No plan of care for know difficult/traumatic supra pubic catheter change Why? No plan of care for known difficult supra pubic catheter patient Nurse was not aware of the need to inform the multi-displicianry team Not part of current training programme. Training programme not updated for over 3 years Training programme not undated for over 3 years The policy for catheter care was out dated Policy for catheter care (which includes staff training) is outdated = Root Cause

Other factors – Pre Hospital Activity Contributory factors Documentation Poor legibility Lack of chronology and significant gaps in the records There will be other findings from the analysis regarding general aspects of care that must also be addressed. Collect feedback from the groups Use this slide as an example Compare and contrast with the group findings

Delayed diagnosis of MRSA – Hospital Activity Problems 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 You 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.

What are the root causes? RCA Review What 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 systems Root Cause Lack of integrated care pathway of catheter management

Session 7 Summary

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: http://www.hpa.org.uk http://www.npsa.nhs.uk http://www.dh.gov.uk 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.