root cause analysis and just culture: a practical ... · framework to employ root cause analysis...
TRANSCRIPT
ROOT CAUSE ANALYSIS AND JUST CULTURE: A PRACTICAL APPLICATION TO DRIVE IMPROVEMENT
Sheila Yates, MPH, CPHQ
OBJECTIVES
Participants will gain an understanding of Just Culture as a framework to employ Root Cause Analysis (RCA) at their own sites
Participants will gain an understanding on RCA as a tool for evaluation of clinical and administrative quality issues
Participants will practice RCA using scenarios and be able to replicate use of the tools with their own teams
A Just Culture is Defined as :
A fair and consistent environment that fosters open
communication, transparency, voluntary error reporting,
information sharing and a willingness to do the right thing!
Just culture is about:
A fair and consistent environment, open communication and a focus on learning
Reviewing contributing factors then determining accountability
Creating systems that promote patient safety
Including human error factors and systems thinking
Cutting across all levels of staff
Reinforcing the roles of risk and continuous quality improvement
NAME/BLAME/SHAME CYCLEEmployee
takes action that
contributes to error
Employee is punished
Reduced trust as
employee view as
“scapegoat”
Employees become
silent (CYA) less
reporting
Management less aware
of conditions
Errors more likely
DETERMINING INDIVIDUAL VERSES SYSTEM ACCOUNTABILITY
•Deliberate Act Test: Did the employee intent the act or the outcome?
•Incapacity Test: Did the employee come to work impaired
•Compliance Test: Did the employee knowingly and unreasonably increase risk?
•Substitution Test: Would another similarly trained employee in the same situation act in a similar manner?
FINAL WORD
We are all human and humans are not perfect
No one should be punished for reporting an “honest” mistake
We can’t fix something if we don’t know it’s broken
We all own the responsibility for speaking up and reporting
Be willing to expose areas of weakness as much as areas of excellence
WHAT IS ROOT CAUSE ANALYSIS?
A problem-solving approach to identify the underlying causes of problems or events
The goal is to discover:
oWhat happened?
oWhy did it happen?
oWhat can be done to prevent recurrence?
The outcome is a structured plan to prevent future events
WHEN SHOULD YOU DO AN RCA?
Following a serious event
If a trend shows an increase in errors
To solve system issues
To improve customer service
SETTING THE STAGE
Schedule RCA meeting as soon as possible so that memories are fresh
Clearly communicate the purpose of the meeting
Team should be those involved in the event
Establish ground rules:oAvoid blaming or finding fault
oCommit to finding solutions
METHODS TO DETERMINE WHAT HAPPENED
Recreate the sequence of events and learn the basic facts by:
Investigative individual interviews
Chart or record audits
Group processing
CAUSE AND EFFECT DIAGRAMS
Cause and effect diagrams also called Ishikawa diagrams or more commonly called fishbone diagrams are used to map out the causes of a specific event
They are best used to identify and explore potential root causes in a detailed and graphic manner often in a group setting
They allow the team to see causes related to a process, procedure or system failure
CONTRIBUTING FACTORS CATEGORIES People : Staff
People: Patient
Communication
Environment
Equipment & Supplies
Policies & Procedures
Leadership Activities
5 WHYS
A method used to explore the underlying relationship of a problem by looking at the cause and effect.
Helpful when problems involve human factors and interactions
You may need one “why” or you may need six
FINAL REPORT AND ACTION PLAN
All action plans should identify specific action items, measures of effectiveness, the time frame and staff accountability.
The facilitator should commit to the time/date of when the final RCA summary will be sent to the team members for review.
The team should be thanked for taking the time to participate in this important process and often a brief a meeting evaluation tool is used to gather feedback on the overall process.
BEST PRACTICES
Do not include any patient identifying information on RCA notes
Be aware of any state specific requirements - check with your local counsel
Update policies based on event findings
Try on a more minor event first – get familiar with the tools
As the facilitator, it is your role to keep the pace moving, it is very easy to get side tracked.
ENGAGING LEADERSHIP
Provide overview on the benefits of the RCA process and implementation a Just Culture program
Discuss what is currently happening and preventative strategies
Inform them upon RCA completion
Discuss the team’s action plan
Ask them how they would like to be involved
GROUP ACTIVITY
Break into groups of 4-5
Using Fishbone template and Contributing Factors handouts, choose one of the scenarios (or one of your own) to practice filling in the Fishbone template
Time: 15 minutes
A CHALLENGE TO YOU
Integrate Just Culture into your policies and procedures
Reinforce the importance of reporting incidents and learning from mistakes
Build trust and reinforce the importance of inquiry and RCA’s
Provide trainings on Just Culture and RCA tools