The healthcare industry is a pressurized and fast-paced environment loaded with high risk situations. The use of high-tech equipment and the daily decisions and judgements being made by healthcare professionals under stressful situations, further increases the high level of opportunity for human error.
When an error occurs in the healthcare industry, the usual scenario goes something like this: Determine what happened; find the employee who made it happen; fire the employee.
The problem with this approach is that firing the employee often doesn’t fix the cause of the error, which could be repeated by the next employee, and the next, and the next.
This is why the heathcare industry has been proactive in turning to root cause analysis (RCA). Root cause analysis is not a process used to discipline employees. It’s a methodology that digs deeper to understand exactly what happened, why it happened, and what needs to change to prevent future mistakes.
The exact definition of root cause analysis by the American Society of Risk Management in regards to the healthcare industry:
“A systematic analysis of an event or near miss that has occurred within the healthcare setting.”
Common RCA tools utilized in the healthcare industry:
The 5 Whys
This method is simply asking the question “Why” enough times until you get through all the symptoms of a problem and down to the root cause. The 5 Whys is also used in coordination with other analysis tools, such as the Cause and Effect Diagram, but can be used as a standalone tool. The 5 Whys is most effective when the answers come from people who have hands-on experience of the issue being examined. To discover the root cause of a problem, keep asking “why.” By repeating “why,” you can drive down to the root cause of the problem.
Ishikawa Diagram (Fish-Bone)
The Ishikawa or Fishbone Diagram is a useful tool in determining the most likely causes of a quality problem. The diagram is sometimes referred to as a Fishbone Diagram because it looks much like a skeleton of a fish with the effect or problem being listed in a box at the end. The main sections of the diagram are used to address the 6 Ms (Man, Material, Method, Machine, Measurement and Mother Nature (Environment). The diagrams are usually worked right to left, with each large “bone” of the fish branching out to include smaller bones with additional details. Once the team has brainstormed all the possible causes of the problem, the team should rate the potential causes according to their level of importance and likelihood of contributing to the failure and develop a hierarchy. From the hierarchy the team selects which causes to further investigate.
Of course, understanding what happened is only part of the puzzle using the RCA approach. To minimize the likelihood of an error being repeated, healthcare facilities focus on implementing sustainable changes to processes, policies and environment.
In other words, analysis plus action is the objective to help ensure safer patient care and working conditions for staff.
Root Cause Analysis Training
Tonex offers a Root Cause Analysis Training For HealthCare Professionals class, a 3-day course that focuses on a hands-on approach to implementing root cause analysis in healthcare facilities.
This root cause analysis seminar is designed for healthcare managers, nurses, physicians, healthcare facility managers and all healthcare professionals who are involved in root cause analysis investigation at any level.
Related Root Cause Analysis Courses
Tonex also offers these root cause analysis classes:
- The basic three day Root Cause Analysis Training
- The two day Root Cause Analysis Training for Supervisors
- The two day Root Cause Analysis Training for Engineers
- The two day Root Cause Analysis Training for Beginners
— For over 30 years Tonex, while presenting highly customized learning solutions, has worked with organizations in improving their understanding and capabilities in topics often with new development, design, optimization, regulations and compliances that, frankly, can be difficult to comprehend.
— Ratings tabulated from student feedback post-course evaluations show an amazing 98 percent satisfaction score.
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