By Tejal K. Gandhi, MD, MPH, CPPS
|| Tejal K. Gandhi
In the almost two years that I’ve served as president of the National Patient Safety Foundation, one of the topics I’ve heard about a lot is the challenge of conducting an effective root cause analysis (RCA). Who decides when an RCA is needed? Who is on the investigatory team? How do we focus on systems and not appear to be on a hunt to assign blame?
With a grant from The Doctors Company Foundation, NPSF recently convened an expert panel to look at these and other challenges and to develop guidelines to help health care professionals and their organizations improve the way they conduct RCAs. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm is available as of today on the NPSF website, and I hope you’ll take the time to review this useful document.
This report provides a structure and brings together tools to help in the RCA process. In my estimation, the three chief recommendations to absorb are:
1. Use a risk-based case selection to prioritize RCAs. RCA is still most often conducted after harm has occurred. With a risk-based prioritization system, organizations can address hazards before they occur. Risk-based prioritization is consistent with the practices used in aviation and other high reliability organizations. A standardized method of assigning probability and severity also helps organizations determine where and when to utilize their (usually limited) resources.
2. Be sure to include strong actions. We named our report RCA2 (“RCA squared”), with the second A representing actions. When RCA is conducted after harm occurs, the chief question is often “how did this happen?” This new report emphasizes the need to take strong action to help ensure that it does not happen again. The document highlights examples of weak and strong actions and emphasizes that your RCA2 is not complete unless you have stronger actions.
3. Leadership involvement in oversight and review of effectiveness. Any RCA2 process can only be effective with support of the organization’s leaders, including board members. It is they who can commit the appropriate resources to establishing a robust system; approve or disapprove any actions recommended by the RCA2 team; and determine if the RCA2 findings and recommendations need to be shared widely within or outside of their organization.
If you’ve been involved with conducting an RCA for your organization, or even if you want to know more about why and when RCAs should be conducted, this report is worth a look. I hope you’ll take the time to review it and let us know what you think.
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm will be discussed during an open webcast on July 15, 2015, from 1:00 to 2:00pm Eastern Time. Registration is free of charge. Learn more.
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