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Root cause analysis

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Manal Elsayed CPPS, CPHQ, CLSSBB, FISQua, DTQM
Manal Elsayed CPPS, CPHQ, CLSSBB, FISQua, DTQM

Root cause analysis

Healthcare
1 of 23
DR. MANAL ELSAYED ABDELAZIZ B.Sc.Pharm, CPHQ, DTQM, CLSSGB TeamSTEPPS Master Trainer
WHAT IS YOUR REACTION? STOP IT (PERMANENTLY) MOP IT (TEMPORARY)
ROOT CAUSES • If the root cause of a problem is not identified, then one is merely addressing the symptoms and the problem will continue to exist. • Three basic types of causes: • Physical • Human • Latent/Organizational
ROOT CAUSE ANALYSIS • It is a systematic process used for identifying the most causal factors underlying variation in performance. • Used for intensive/in-depth analysis of an event. • Is a retrospective (reactive) attempt to determine the cause of a sentinel event, such as an unexpected death.
THE RCA SEEKS TO ANSWER FOUR QUESTIONS: 1. What happened? 2. Why did it happen? 3. What are we going to do to prevent it from happening again? 4. How will we know that the changes we make actually improve the safety of the system?
HOW RCA TAKE PLACE? 1- Form a team 2- Define the problem: What happened? 3- Analyze the process 4- Perform safeguard analysis 5- Ask WHY? 6- Recommend actions 7- Action plan 8- Report your findings 9- Evaluate effectiveness
FORM AN RCA TEAM • It’s hard, if not impossible, to answer these questions alone. Health care is complex, and understanding what led to an error requires diverse perspectives on how the system really works. • In an RCA, an interprofessional team approach is used to understand the specific error that occurred.
FORM AN RCA TEAM • Including senior leaders of the organization is not necessary. • In fact, it is better to include people on the team who have direct involvement in the processes under study. • If senior leaders are on the team, people may feel intimidated when asked about what happened. • And that might in turn limit participation in the RCA!
DEFINE THE PROBLEM: WHAT HAPPENED? • This step is the information-gathering phase of the root cause analysis. Within this step, the team must try to describe what happened accurately and completely. • During the interviews, the team focuses on identifying what happened, not why it happened. They encourage the different staff members to speak freely and emphasize that the purpose of the RCA is to learn from the event and not place blame.
ANALYZE THE PROCESS HIGH LEVEL FLOWCHART (AS-IS)
PERFORM SAFEGUARD ANALYSIS DETERMINE WHAT SHOULD HAVE HAPPENED.
PERFORM SAFEGUARD ANALYSIS DETERMINE WHAT SHOULD HAVE HAPPENED. • Once the team has clearly identified what happened, they must now move on to determining what would have happened. • This may involve reading through hospital policies, reviewing medical literature, or interviewing department directors to find out about barriers to safe practice.
DETERMINE CAUSES :ASK WHY! • One useful tool for identifying factors and grouping them is a FISHBONE DIAGRAM. • Sometimes called an “ISHIKAWA” or “CAUSE AND EFFECT” diagram, this is a graphic tool used to explore and display the possible causes of a certain effect.
A. Multivoting technique DEFINE THE ROOT CAUSE…PRIORITIZE!
DEFINE THE ROOT CAUSE…PRIORITIZE! B. Pareto diagram
RECOMMEND ACTIONS •Identify all the countermeasure options available against the root causes in order to prevent or minimize the probability of recurrence due to the same root cause.
DEVELOP YOUR ACTION PLAN ACTION STEP What needs to be done? RESPONSIBLE PERSON Who should take action to complete this step? DEADLINE When should this step be completed? NECESSARY RESOURCES What do you need in order to complete this step? POTENTIAL CHALLENGES Are there any potential challenges that may impede completion? How will you overcome them? RESULT Was this step successfully completed? Were any new steps identified in the process?
REPORT YOUR FINDINGS • Communicate findings and actions required or already taken to resolve the problem situation. • Report to administration/management, all involved parties, and regulatory agencies as relevant .
EVALUATE YOUR ACTIONS • Evaluate effectiveness of action implementation and efficiency of RCA • Find out: Has the risk of recurrence actually been reduced?
Root cause analysis

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Root cause analysis

  • 1. DR. MANAL ELSAYED ABDELAZIZ B.Sc.Pharm, CPHQ, DTQM, CLSSGB TeamSTEPPS Master Trainer
  • 2.
  • 3. WHAT IS YOUR REACTION? STOP IT (PERMANENTLY) MOP IT (TEMPORARY)
  • 4. ROOT CAUSES • If the root cause of a problem is not identified, then one is merely addressing the symptoms and the problem will continue to exist. • Three basic types of causes: • Physical • Human • Latent/Organizational
  • 5. ROOT CAUSE ANALYSIS • It is a systematic process used for identifying the most causal factors underlying variation in performance. • Used for intensive/in-depth analysis of an event. • Is a retrospective (reactive) attempt to determine the cause of a sentinel event, such as an unexpected death.
  • 6. THE RCA SEEKS TO ANSWER FOUR QUESTIONS: 1. What happened? 2. Why did it happen? 3. What are we going to do to prevent it from happening again? 4. How will we know that the changes we make actually improve the safety of the system?
  • 7.
  • 8. HOW RCA TAKE PLACE? 1- Form a team 2- Define the problem: What happened? 3- Analyze the process 4- Perform safeguard analysis 5- Ask WHY? 6- Recommend actions 7- Action plan 8- Report your findings 9- Evaluate effectiveness
  • 9. FORM AN RCA TEAM • It’s hard, if not impossible, to answer these questions alone. Health care is complex, and understanding what led to an error requires diverse perspectives on how the system really works. • In an RCA, an interprofessional team approach is used to understand the specific error that occurred.
  • 10. FORM AN RCA TEAM • Including senior leaders of the organization is not necessary. • In fact, it is better to include people on the team who have direct involvement in the processes under study. • If senior leaders are on the team, people may feel intimidated when asked about what happened. • And that might in turn limit participation in the RCA!
  • 11. DEFINE THE PROBLEM: WHAT HAPPENED? • This step is the information-gathering phase of the root cause analysis. Within this step, the team must try to describe what happened accurately and completely. • During the interviews, the team focuses on identifying what happened, not why it happened. They encourage the different staff members to speak freely and emphasize that the purpose of the RCA is to learn from the event and not place blame.
  • 12.
  • 13. ANALYZE THE PROCESS HIGH LEVEL FLOWCHART (AS-IS)
  • 14. PERFORM SAFEGUARD ANALYSIS DETERMINE WHAT SHOULD HAVE HAPPENED.
  • 15. PERFORM SAFEGUARD ANALYSIS DETERMINE WHAT SHOULD HAVE HAPPENED. • Once the team has clearly identified what happened, they must now move on to determining what would have happened. • This may involve reading through hospital policies, reviewing medical literature, or interviewing department directors to find out about barriers to safe practice.
  • 16. DETERMINE CAUSES :ASK WHY! • One useful tool for identifying factors and grouping them is a FISHBONE DIAGRAM. • Sometimes called an “ISHIKAWA” or “CAUSE AND EFFECT” diagram, this is a graphic tool used to explore and display the possible causes of a certain effect.
  • 17. A. Multivoting technique DEFINE THE ROOT CAUSE…PRIORITIZE!
  • 18. DEFINE THE ROOT CAUSE…PRIORITIZE! B. Pareto diagram
  • 19. RECOMMEND ACTIONS •Identify all the countermeasure options available against the root causes in order to prevent or minimize the probability of recurrence due to the same root cause.
  • 20. DEVELOP YOUR ACTION PLAN ACTION STEP What needs to be done? RESPONSIBLE PERSON Who should take action to complete this step? DEADLINE When should this step be completed? NECESSARY RESOURCES What do you need in order to complete this step? POTENTIAL CHALLENGES Are there any potential challenges that may impede completion? How will you overcome them? RESULT Was this step successfully completed? Were any new steps identified in the process?
  • 21. REPORT YOUR FINDINGS • Communicate findings and actions required or already taken to resolve the problem situation. • Report to administration/management, all involved parties, and regulatory agencies as relevant .
  • 22. EVALUATE YOUR ACTIONS • Evaluate effectiveness of action implementation and efficiency of RCA • Find out: Has the risk of recurrence actually been reduced?