Publish Date: February 12, 2020
Root cause analysis (RCA) is a valuable tool to understand areas for improvement, whether a patient safety issue is local or a system-level concern. However, not every RCA is as successful as it could be, notes Kathleen Law, DNP, MS, RN, CNOR, former vice president of nursing for perioperative services at Penn State Health, Milton S. Hershey Medical Center in Hershey, Penn.
Serving in various roles on RCA committees throughout her career and reviewing RCAs through her position on the board for the Pennsylvania Patient Safety Authority has given Law a unique perspective on what makes an RCA effective.
“Implementation of RCA findings should be an integral part of the analysis process,” she stresses, because too often important findings from an RCA are not implemented in a sustainable way.
Law notes that a focus on implementation is now part of the Institute for Healthcare Improvement’s RCA2 approach to event review. “You need a constant feedback loop for auditing changes implemented from RCA findings to make sure the changes are effective.”
How good is your RCA process?
While Law has seen the RCA process gain in popularity in perioperative care over the past decade, she is concerned that a lack of training by those overseeing an RCA could lead to failure.
Here are five ways Law suggests a perioperative leader can ensure a successful RCA process:
- Appoint a Strong RCA Facilitator
The facilitator should have a strong background in the RCA process and also have the clinical knowledge to understand the content of the RCA and who to involve and/or interview. “If you are not familiar with the RCA process, engage with your patient safety officers or quality department to feel confident in leading the complete event review,” Law advises.
- Involve the Right People in the Right Way
Think through how those involved in the patient safety event can best contribute to the RCA process. For example, different care providers, including the surgeon, may be able to provide a unique and beneficial perspective on patient safety issues. Also think about the emotional state of those involved and how feelings of guilt could influence someone involved in the RCA, Law cautions.
- Allocate Time
Provide dedicated time for all RCA participants to contribute within their regular work hours because dedicated time is needed for the RCA review process and any investigatory work, she suggests. “Too often people going about their day-to-day work activities are asked to squeeze more time in for RCA work, which can create challenges for effective participation.”
- Engage Staff From All Shifts
The RCA investigation and any changes implemented from RCA findings should consider care activities and other processes on all shifts. “Things happen differently on day versus night shifts and you want to ensure that RCA recommendations are feasible for all,” Law says.
- Share Findings Broadly
Make sure to remove any barriers to implementing practice changes (if changes are developed) by clearly communicating what you find from the event review—"good, bad or indifferent,” Law stresses. She says most organizations have a formal process for sharing RCA findings, however, leaders can also share with staff via newsletter, email or other avenues.
“Consider how you might share your findings beyond your department and organization,” she adds. “Often you might think you are dealing with a unique problem in your area, but perhaps leaders from another procedural area or perioperative department have already worked on this issue and can share their insights.”
Learn more from Law about refining your RCA process in the Leadership Summit at AORN’s Global Surgical Conference and Expo in Anaheim, Calif., March 28 to April 1.
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