Common mistakes made during root cause analyses
Here are common mistakes made by organizations performing root cause analyses (RCA), with solutions offered by Claire Davis, vice president of quality at Norwalk (CT) Hospital:
Problem: Staff are unable to describe the exact process as it occurred.
Solution: To avoid "holes" in the end-to-end process description, only hold the RCA if staff directly involved in the process and event are at the table.
Problem: Participants are participating in guilt and blame behaviors.
Solution: Use an RCA script as a scientific tool.
Problem: A group jumps ahead to developing an action plan before thoroughly identifying end-to-end causes.
Solution: Have a strong leader and facilitator keep the group on track.
Problem: Unit staff are reluctant or fearful to "tell the truth."
Solution: Act on any individual performance problems, as opposed to systems problems, outside of the RCA forum.
"I do not invite anyone, including managers, supervisors, or VPs, unless they were a direct part of the process I am studying," says Davis. "Leaders are brought into the process via direct reports of findings and corrective action plans by me, in my position as VP of quality. This allows me to seek their support."
Problem: There is a failure to "close the loop" on all corrective action plan action items, and failure to do ongoing monitoring of success.
Solution: Copy the RCA corrective action plan, which is blinded for reasons of peer review protection, to each person responsible for an action and to the vice presidents of each person with an action. The RCA and action plan is also presented to the board quality committee, with a report of closure of all actions scheduled for committee review immediately following the date of the final action on the plan.
Problem: Peer review or debriefing is "masquerading" as an RCA.
Solution: Don't allow anyone, whether novices or legitimate leaders, to conduct an RCA unless they have been trained and deemed competent. "I have witnessed poorly run debriefings, called RCAs, fail," says Davis. "The result is that people do not want to attend future legitimate RCAs."
Here are common mistakes made by organizations performing root cause analyses (RCA), with solutions offered by Claire Davis, vice president of quality at Norwalk (CT) Hospital:You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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