Executive Summary

The National Patient Safety Foundation (NPSF) has revised its guidelines for conducting root cause analyses.

• The “A” in the acronym has been emphasized to indicate the need for action in addition to analysis.
• The analysis should include reporting back to whoever initially reported the event.
• Those directly involved in the event should be excluded from the analysis.

---

Analysis is good, but acting on that information is what really makes a difference. That’s the message from the National Patient Safety Foundation (NPSF) in Boston, which has revised its guidelines for conducting a root cause analysis (RCA).

The guidelines, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm, have been endorsed by several related organizations and is being widely distributed to hospitals, health systems, and other settings. The American Society for Healthcare Risk Management did not endorse the guidelines or participate in their development. (The guidelines are available online at http://tinyurl.com/prhkxv9.)

With a grant from The Doctors Company Foundation, the NPSF convened a panel of subject matter experts and stakeholders to examine best practices around RCAs and develop guidelines to help health professionals standardize the process.

“We’ve renamed the process RCA2 — RCA squared — with the second “A” meaning action, because unless real actions are taken to improve things, the RCA effort is essentially a waste of everyone’s time,” co-chair of the panel James P. Bagian, MD, PE, explained when the guidelines were announced. Bagian is a member of the NPSF Board of Governors and director of the Center for Health Engineering and Patient Safety at the University of Michigan in Ann Arbor. “A big goal of this project is to help RCA teams learn to identify and implement sustainable, systems-based actions to improve the safety of care,” Bagian said.

One member of the panel was Ailish M. Wilkie, MS, CPHRM, CPHQ, senior project manager in patient safety and risk management with Atrius Health Patient Safety & Risk Management, a non-profit alliance of health systems in Massachusetts. She and the other panel members concluded that risk managers and other healthcare leaders often fall short in acting on what they found during an RCA.

“We do a great job of performing RCAs, but the actions and the measurement of those improvement actions is something that we all have an opportunity to improve,” Wilkie says. “Standardizing how we do RCAs, by following the NPSF process, will help us all conduct more successful RCAs.”

The action part of an RCA should include closing the loop with staff or physicians who reported the event, she says. Risk managers must counter the common notion that any concerns reported to administration disappear in a black hole and are never heard again, Wilkie says. Communicating with those individuals about the RCA’s findings will encourage people to report their concerns more often in the future, she says.

Elevating the RCA process might be most challenging for smaller hospitals, she says, for the same reason that they already might find it difficult to do a thorough RCA: lack of staff, time, and other resources. The revised NPSF guidelines should be useful for smaller facilities, nonetheless, because they provide a framework that can make RCAs consistent from one facility to another, regardless of size, she says.

“The guidelines also can help us get back to some of the best methodology that we might have done when we first started conducting RCAs but which have fallen out of practice along the way,” Wilkie explains. “For instance, the new guidelines suggest that the individuals who are directly involved in the event not be part of the RCA team. That might have been a best practice in the beginning, but some smaller organizations can find it hard to exclude the people directly involved because that person might be the only one in the department.”

Those directly involved in the event should be excluded from the RCA whenever possible because they might come to the table with preconceived ideas, Wilkie explains. Ideally, every RCA participant should begin with no preconceptions about what happened or why, which is a goal that is more easily met by a large organization with many people qualified to participate, she says.

The NPSF guidelines also emphasize that some adverse events are not appropriate for an RCA.

“RCA2 processes are not to be used to focus on or address individual health care worker performance as the primary cause of an adverse event, but instead to look for the underlying systems-level causations that were manifest in personnel-related performance issues,” the guidelines state. “A common definition of blameworthy events includes events that are the result of criminal acts, patient abuse, alcohol or substance abuse on the part of the provider, or acts defined by the organization as being intentionally or deliberately unsafe.”

Start within 72 hours

The new guidelines encourage beginning an RCA within 72 hours, but Wilkie notes that the NPSF doesn’t necessarily mean convening the investigators for the first meeting of the RCA team within that time. Rather, the initial investigation should begin within that time limit by reviewing the patient chart and creating a timeline of events.

“That’s something that can be done by the risk manager and doesn’t need the RCA team as a whole,” Wilkie says.

Another new emphasis is on the idea that an RCA is a normal part of work for those involved, rather than seeing it as something abnormal and outside the regular scope of work. For example, NPSF recommends that RCA sessions be held during normal business hours and treated as an ordinary part of the employee’s time at work. That approach helps prevent staff from seeing the RCA process as a burden or added duty, Wilkie says.

“Sometime physicians can’t meet with you during normal hours because they’re too busy with patients, so convening after hours might be unavoidable,” Wilkie says. “But to the extent you can, you want to foster the idea that and RCA is an important but standard part of what we do to improve quality and safety.”

SOURCE

• Ailish M. Wilkie, MS, CPHRM, CPHQ, Atrius Health Patient Safety & Risk Management. Newton, MA. Telephone: (617) 559-8269. Email: ailish_wilkie@atriushealth.org.