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:

• The Safety Advisory Panel provides moral support for the teams working on interventions.

"The teams know that someone believes in what they are doing," says Griffin.

• The panel provides access to resources that the teams may not have known about, and/or may not have been able to access on their own.

"The expertise of the engineering department to help redesign or enhance a device, or of the Simulation Center in setting up a new training model, are both examples of such resources," says Griffin.

• The panel pushes the teams to think outside of the box and stretch themselves, in terms of interventions and measurement strategies.

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.

• The panel reviews intervention plans early enough to be able to influence their direction.

"Occasionally, the panel will uncover a stated root cause that really isn't a root cause, but is actually a contributing factor," 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 assists teams in thinking through the measurement strategy, occasionally spotting less than robust strategies. Advice is given on how to improve these.

"The panel has a finger on the pulse of what else is happening across the institution, so we don't reinvent wheels," says Griffin. "In the end, the panel holds the teams accountable to do and to measure what they tell us they are going to do and measure."

Some improvements that were made as a result of the RCA process include:

• Engineering worked with nursing to design a connector clip to be used with dialysis tubing.

• Pharmacy added medications to its "look alike/sound alike" computer-based alert system.

• The Simulation Center developed new training scenarios.

• Human factors and ergonomics assessments were completed in procedural and storage areas.

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: griffin.bridget@mayo.edu.]