RCAs need leaders' care and feeding

Leaders bring greater likelihood of success

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

The greater amount of top leadership involvement in a root cause analysis (RCA), the greater the likelihood of significant patient safety improvements. Senior leaders don't need to be appointed to RCA teams but some level of leadership oversight and intervention is important throughout the life of the investigation. Root cause analysis teams should not be formed and then abandoned by leaders until the investigation is complete. What must leaders do to ensure a successful RCA? Participation starts even before the investigation is initiated and continues long after the review is done. The steps of an event investigation and the role of leaders at each step is summarized in Figure 1.

Determining whether an RCA is necessary

Following a significant adverse event or undesirable clinical outcome, senior leaders should be involved in determining whether an RCA is to be done. Many factors will be considered in making this determination, including, but not limited to, the following:

  • Does this event represent a substantial risk to patient safety?
  • Is this event due to faulty processes or system failures that are likely to cause a similar, perhaps more harmful event, if not corrected?
  • Will the organization receive substantial negative publicity if the cause of the event is not corrected?
  • Will failure to conduct an RCA result in deterioration of staff or physician morale and/or loss of trust in the leaders' commitment to patient safety?

A multidisciplinary group, such as the patient safety committee, could be charged with triaging events or the task can be delegated to a smaller group of senior leaders such as the CEO, chief nursing officer, and the medical director or medical staff president. Even if an RCA is required by accreditation standards or state regulations, senior leader endorsement of the investigation is very important. Through this endorsement, leaders are communicating a vital message to everyone — finding and fixing root causes is a high priority for this organization and not something we are doing just to satisfy an external requirement.

Initial screening process

During this initial event screening process, leaders also can decide whether the case needs a thorough risk management investigation, peer review evaluation, and/or staff performance review. An RCA focuses primarily on systems and processes, not management of potential liability risks or evaluation of individual performance. These additional reviews can be conducted simultaneously with the RCA, but never in the same forum. Events not chosen for an RCA should be considered by the organization's leaders when establishing future patient safety improvement priorities.

Throughout the investigation, the RCA team facilitator should keep leaders informed. If some people are not showing up for the meetings or other issues are slowing the progress of the RCA, the leadership group often needs to intervene to resolve problems. When the RCA has reached the action planning stage, it is useful for the team facilitator to get input from relevant administrative and medical staff leaders. The following are issues that often need clarification before the RCA team finalizes the action recommendations:

  • Are there pre-set assumptions that leaders hold about the recommended actions? Are leaders open to accepting the team's recommendations or do they have alternatives?
  • What resources (dollars, time, etc.) can be spent on the action plans? What are the resource limitations?
  • What will make leaders anxious during the action design and implementation phase? How soon do they expect to see positive changes?
  • If a process owner does not complete their assignments will leaders initiate appropriate pressure to correct the problem?
  • Will leaders help dismantle the "old way" of doing things by holding fast to and reinforcing the redesigned way until it has had time to prove its effectiveness?
  • Are the desired time frames for short, medium, and long-term action plan completion realistic? Can leaders support these time frames?

Once the RCA team finalizes corrective actions and identifies measures of success, the completed investigation report is forwarded to the leadership group or committee. This group should evaluate the thoroughness and credibility of the investigation and the merit of the action plans. Thoroughness and credibility is evaluated by considering the following questions:

  • Did the root cause analysis have multidisciplinary participation and input from those closest to the processes and systems under review?
  • Does the report clearly document the facts surrounding the event or hazardous condition?
  • Did the team follow a logical and systematic process to identify the root causes of the event or hazardous condition?
  • Did the team identify root causes (underlying system failures or process faults) that if addressed are likely to prevent recurrence of the event or reduce the hazardous condition?

The merit of the action plans is evaluated by considering the following questions:

  • If the recommended actions are taken, is it likely that future events of this type will be eliminated or reduced?
  • Can the actions be implemented within a reasonable time considering available financial and human resources?
  • Are the people/departments responsible for implementing actions clearly identified and are the timelines for completion reasonable but aggressive?
  • Will the measures of effectiveness adequately evaluate the success of the actions?

If the group leader does not approve the RCA, the team should be reconvened to address questions or concerns and make necessary changes. Upon completion of their charge, the team presents a new report to the leaders for review and approval.

When the RCA is complete and approved, a leadership group should receive regular reports of the progress of action plans and the results of success measures. The leaders need to evaluate whether action plans are being implemented as envisioned and if milestones are being achieved. Once the "fire" stops blazing after a significant adverse event, attention can sometimes move on to other issues and the root causes don't get resolved. If this happens, leadership intervention is needed to hold people accountable for their role in implementing action plans — otherwise things will drift back to how they were prior to the RCA.

If the actions do not achieve desired results, the RCA team should be reconvened to discuss and recommend revisions to the initial action recommendations. The leadership group should monitor the effectiveness of actions until such time as the group is reasonably assured that the actions achieved desired results (usually at least six months following implementation of the recommendations). Another important role for the leadership group is to make sure that improvement ideas derived from the event investigation are periodically shared with managers, staff, and medical staff members. Such sharing helps broaden organizational learning from each RCA.

Senior administrative and medical staff leaders must allocate appropriate time and attention to RCA activities to encourage ongoing patient safety improvement. An important aspect of this oversight is participation in each step of the investigation. By selecting events that will undergo an RCA, leaders are reinforcing the importance of such investigations. By reviewing the ongoing progress of the RCA, leaders can clear away barriers and help support implementation of worthwhile, cost-effective improvement plans. By enforcing accountability for completing actions and achieving improvement goals, leaders help assure and sustain patient safety gains.