Length: 3 Days
Root Cause Analysis Training For Healthcare Professionals
One of the main objectives of using Root Cause Analysis (RCA) in the healthcare sector is to help organizations study events that resulted in patient harm or undesired clinical outcomes and identify strategies to reduce future error and improve patient care and safety.
Studies are clear that Root Cause Analysis can help identify medication errors such as illegible handwritten prescriptions, similar name packaging or misleading presentations of drug strength or dosage, ineffective control of prescription labels, and lapsed concentration due to interruptions.
Clinician participation in RCA is vital as these initiatives recognize and address important patient care aspects.
In the U.S., the Joint Commission accredits and certifies more than 22,000 healthcare organizations and programs including hospitals and healthcare organizations that provide ambulatory and office-based surgery, behavioral health, home healthcare, laboratory and nursing care center services.
Through a review of data gathered by the Joint Commission, six common categories of clinical error resulting in patient death, which can be prevented through Root Cause Analysis, have been identified:
- Wrong-site surgeries
- Patient suicide
- Surgical complications
- Medical treatment delays
- Medication errors
- Patient falls
Generally, when RCA is needed for healthcare professionals, this task would be assigned to a small team consisting of 4 to 6 individuals who have fundamental knowledge of the specific area involved.
Team members should consist of physicians, supervisors, ancillary staff and quality improvement experts.
It is important that members of the RCA healthcare team not be involved in the case being reviewed to ensure objectivity. Time to completion of an RCA varies depending complexity of the case, time required to conduct interviews and synthesize information, and barriers to implementation of corrective actions; however, a typical investigation should range between one to three months.
Root Cause Analysis for healthcare generally consists of a process that includes:
- Honest and open reporting of adverse events
- Identifying appropriate RCA investigations
- Organizing an RCA team
- Developing and initial flow diagram
- Developing an event story map
- Developing a cause and effect diagram
- Identifying Root Cause contributing factors
- Developing corrective actions
- Measuring outcomes
- Communicating results
Root Cause Analysis Training For Healthcare Professionals Course Description
Root cause analysis training for healthcare professionals covers the concepts and rationale behind root cause analysis (RCA) methodologies, as well as tools, techniques, and the strategies should be applied in order to execute an effective root cause analysis process.
Root cause analysis (RCA), even though, comes from the manufacturing engineering field, it has been adopted by healthcare system and hospitals to study the events associated with patient safety and smooth the organizational learning process. In spite of the RCA evidence base, healthcare regulators and strategy makers have tried to develop training programs to construct the local ability and competencies, and this is a keystone of many organizational standards and strategies for investigating safety-critical matters. Therefore, root cause analysis training for healthcare professionals intends to educate the foundation of this useful methodology and to improve the required skills of the participants so that they can develop and execute successful root cause analysis processes on their own in their healthcare organizations.
Root cause analysis training for healthcare professionals course aims to deliver you with a good comprehension of the RCA process, containing information and sources to allow newly adopted skills to be applied in a workplace. The course focuses on training the participants to simplify RCA in order to manage patient safety events. Hence, this hands-on course is offered in a highly interactive and practical seminar style. We encourage the participants to bring in, use, and evaluate their own patient safety cases.
Root cause analysis training for healthcare professionals is a 3-day course designed for:
- Healthcare managers
- Hospital, clinics, and healthcare facility managers
- All healthcare professionals who are involved in root cause analysis investigation at any level
Upon the completion of root cause analysis training for healthcare professionals, the attendees are able to:
- Understand the history of RCA
- Understand the definitions associated with RCA
- Comprehend the theory of RCA
- Demonstrate an in-depth knowledge of RCA process
- Work through a patient safety even using RCA
- Efficiently facilitate RCA investigations
- Apply other useful patient safety resources
- Establish effective action and preventive plan
- Evaluate the effectiveness of their action plans in patient safety
Overview of RCA in Healthcare
- RCA definition
- RCA background
- RCA applications in healthcare system
- RCA concerns in healthcare
- Where can you use RCA?
- Who should be involved in RCA?
- RCA dictionary
How a Root Cause Analysis Works
- Building your RCA team
- Evaluating what happened
- Recognizing what should have happened
- Identifying causes (“Ask why five times”)
- Creating causal statements
- Developing an outline of recommended actions to inhibit the repetition of the incident
- Write a summary and share it
Features Impact Clinical Exercise and Medical Error
- Patient personalities
- Task features
- Individual personnel
- Team factors
- Work ecosystem
- Organizational and management features
- Institutional framework
How a RCA Can Enhance Healthcare?
- Standardizing instruments
- Ensuring of redundancy, such as using double checks or backup systems
- Applying compelling tasks that physically inhibit users from making common errors
- Modifying the physical plant
- Upgrading or enhancing software
- Applying cognitive assistances, such as checklists, labels, or reminder equipment
- Simplifying a procedure
- Training the staff
- Creating new strategies
Action Categories Defined by the National Center for Patient Safety
- Strong action
- Remove or greatly decrease the probability of an incident
- Intermediate action
- Control the root cause or vulnerability
- Weak action
- Less likely to be efficient by itself
- Evaluation by an inter-professional team expert in the processes tangled in the event
- Analyzing the systems and processes instead of individual performance
- In-depth assessment applying “what” and “why” investigations until all features of the process are evaluated and giving features are studied
- Determining the possible modifications that could be made in systems or processes to enhance the performance and cut down the possibilities of similar opposing incidents or close calls in the future
Guidelines to Expose the Potential Causes Led to The Incident
- Barriers and Restrictions
- Principals, guidelines, and protocols
Healthcare RCA Methods
- Design, contributors, and establishing
- Data collection
- Statistical consideration
- Ethical appraisal
- Strengths and limitations
Establishing Sequence of Events (Initial Flow Diagram)
- A chronological outline of the story
- Provides equal understanding of the event
- Twig the facts
- Establishing the series of events
- Determining what caused the event and what to do to prevent it
- Including only the crucial events
- Using diagram/storyboard to re-structure if “sticky notes” are used
- Applying tools and methods
- The initial flow diagram should make clear what you know and what you don’t know
- Visiting the scene of the event, using the instruments, and safely simulating what happened
Action Plan Development
- Root cause/contributing factor statement
- Outcome measure
- Responsible person
- Management concurrence or non-concur
- Including all actions recommended by the RCA team
- Choosing some intermediate or stronger actions
- Recognizing who will be responsible to execute the action and review the action plan
- Communicating the actions with a “cold” reader to see if they make sense
- Measuring the outcome
Iterating the Actions
- Finalizing the written RCA document
- Ensuring of free error reports
- Retaining the RCA report
- Keeping the Patient Safety Information System (SPOT) updated
TONEX Hands-On Workshop Sample
Mr. John Smith, 74 years old, has had an ordinary medical history until May 2003 when he visited his GP for the constant hiccups he had for one week, he was sent home with some meds for the hiccups. Two hours later he was reported dead due to cardiac problems.
- In small groups, perform a RCA investigation
- Identify the problem
- Determine the potential causes
- Did the doctor miss diagnosed him, or missed crucial symptoms?
- Has he had an allergy to the medicine that he wasn’t aware of?
- Could the hiccups be related to the cardiac issue?
- Outline all the possible causes
- Identify the underlying cause
- Recommend the actions should have been taken to prevent such tragedy
- Recommend preventive actions to avoid similar events to happen again
- Establish an actions and preventive plan
- Discuss your results with the class
Root Cause Analysis Training For Healthcare Professionals