News: Report from NPSF Revitalizes Root Cause Analysis

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A new report from the National Patient Safety Foundation (NPSF) examines root cause analysis (RCA), a process that nearly all health systems use in response to adverse events. Although RCA is commonly used—and in some cases mandated by The Joint Commission—many organizations are unhappy with the process and dissatisfied with the results. The new report addresses deficiencies in RCA and renames the process Root Cause Analysis and Action, or RCA2. The report, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm, is available for download from the NPSF website (www.npsf.org).

This renewed approach to RCA was developed by a panel convened by NPSF with support from The Doctors Company Foundation. The panel was co-chaired by Jim Bagian, MD, PE, and Doug Bonacum, MBA, BS, CPPS. Bagian is currently the director of the Center for Healthcare Engineering and Patient Safety at the University of Michigan. Bonacum is vice president for quality, safety, and resource management for Kaiser Permanente. In July, the two presented a webinar about RCA2, which is also available on the NPSF website.

The report reviews the purpose behind RCA and offers steps for effective implementation, including:

  • identification and classification of events to be analyzed,
  • timing,
  • team membership,
  • analysis steps and tools,
  • measurement,
  • leadership and board support, and
  • sustainability of the RCA2 process.

Throughout the report, the focus is on systems-based improvement, not on individual performance or errors.

The Goal Is to Prevent Harm
The “action” part of the process refers to activities—improve, measure, and sustain—that address system-based problems identified through the RCA2 process. The report emphasizes that the goal is to prevent harm:

It cannot be over-emphasized that if actions resulting from an RCA2 are not implemented and measured to demonstrate their success in preventing or reducing the risk of patient harm in an effective and sustainable way, then the entire RCA2 activity will have been a waste of time and resources (p. vii).

Because analyzing events requires resources and involves various stakeholders, the selection process must be rational and transparent. The report recommends using a system for estimating the risk of future harm and prioritizing events for RCA2:

Use of an explicit, risk-based prioritization methodology lends credibility and objectivity to the process and reduces the chance of misperception by both internal and external stakeholders that decisions to conduct an RCA are inappropriately influenced by political pressure or other factors to cover up problems rather than discover what is in the best interests of the patient (p. 7).

With an accepted and explicit process for prioritization in place, an individual can manage the selection process (i.e., it does not require a committee).

If preventing future harm is the goal, analyzing close calls is as important as analyzing actual events. The report offers the Safety Assessment Code (SAC) matrix and categories from the VA National Center for Patient Safety as helpful for prioritizing events. In the VA’s process, whenever severe harm—actual or potential—is part of the equation, an RCA2 review is done. For example, if a safety event that was caught before harm occurred (a close call) is deemed to be unlikely—but possible—to recur and has potential to cause catastrophic harm, an RCA2 review is warranted.

The SAC matrix results in a numeric score for each event or close call, which provides a simple system for prioritizing them according to risk. Selecting events for review in this manner results in the greatest benefit for the largest population.

In addition to being a practical guide on a subject of great interest to organizations, the RCA2 report from NPSF provides a vigorous review of principles that are foundational to the patient safety movement.

 

FROM THE PSQH ARCHIVES

Root Cause Analysis: Useful Activity or Busy Work?
William A Hyman, ScD; and Robert J. Latino
http://psqh.com/november-december-2014/useful-activity-or-busy-work?

Best Practices for Conducting an RCA: Are There Any?
Shea Polancich, PhD, RN; Linda Roussel, DSN, RN; and Patricia Patrician, PhD, RN
http://psqh.com/september-october-2014/best-practices-for-conducting-an-rca

Improving Reliability with Root Cause Analysis
Robert Latino
http://psqh.com/improving-reliability-with-root-cause-analysis