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Oversight group holds RCA teams accountable
Don't let process get off track
The Joint Commission requires a "thorough and credible" root cause analysis (RCA) for all Sentinel Events, but the process is sometimes less effective than hoped. Quality leaders at the Mayo Clinic came up with a novel solution: An oversight group to keep the process on track.
The teams assigned to perform RCAs are scheduled to meet with the hospital's Safety Advisory Panel a minimum of two times, and more if needed.
"It is through these dialogues, as well as through periodic written reports, that we monitor the teams' progress," says Bridget Griffin, MPH, the hospital's sentinel event program coordinator.
From the very beginning, the team knows it must have a measurement strategy to determine if the intervention was successful or not. Before an event is closed, the measurement data must be assessed and shared with the Safety Advisory Panel.
Here are some benefits:
An example of this is encouraging teams to begin looking closely at their near-miss data. "When possible, they need to monitor and assess those incidents that did not reach the patient, where harm did not occur under the same circumstances, and to ask why it did not occur," says Griffin.
Other times, they will uncover a root cause for which there are no interventions that directly tie back to it. The panel has also discovered interventions already underway that are not tied to the root cause. "For example, sometimes education and training is well intended but does not address the root cause," says Griffin.
The panel is responsible for ensuring that teams identify measurement strategies and collect outcome data.
"However, our root cause analysis process is owned by the departments involved in a root cause analysis," says Griffin.
The departments are responsible for identifying and implementing viable interventions and ensuring that the gains are sustained. "It is the responsibility of the panel and the sentinel event program staff to ensure that teams understand this from the start," says Griffin.
[For more information, contact:
Bridget Griffin, MPH, Sentinel Event Program Coordinator, Quality Management Services, Mayo Clinic, 201 1st Ave SW Suite 3-10, Rochester, MN 55905. Phone: (507) 538-0742. Fax: (507) 266-6806. E-mail: email@example.com.]