Root-cause analysis: Your ally in PI battle
Apparent cause may not be underlying reason
By Patrice Spath, ART
Brown-Spath & Associates
Forest Grove, OR
You must find the underlying reasons for a problem before you can solve it. The best way to do that is through a root-cause analysis (RCA), which provides a systematic approach to identifying why an undesirable condition or problem occurred.
Before you begin, you have to understand the difference between an apparent cause of a problem and the underlying reason. For example, suppose a patient falls and injures herself. The apparent cause might be lack of supervision or a slippery floor. Yet, that apparent cause is probably a manifestation of an underlying root cause, such as an inadequate fall risk assessment being performed.
When an undesirable incident occurs, you must use a logical process to find the event's most probable cause. Here are the seven RCA steps you should incorporate into your sentinel event policies and procedures:
1. Determine what happened. Have a designated person within the organization conduct a preliminary investigation. This may be the quality manager, the risk manager, or another person. This person collects the facts surrounding an event, talks with those directly involved, collects relevant policies and procedures, and gathers any other evidence. It is imperative to do this while events are still fresh in the minds of those involved.
The investigator can then use a flowchart to illustrate the pre-event process. RCA uses an Events and Causal Factors chart that depicts the events and causes for an incident. It helps you see the direct link between each step of a process and root-level or systemic causes of an undesirable event. (See sample chart, p. 137.)
2. Select an investigation team. Bring staff familiar with the processes underlying the event together to conduct the formal investigation. The information gathered by the principal investigator in Step 1 should reveal the logical people to serve on this team. For instance, if you are investigating a fall, your team might include the person in charge of reviewing intake assessments, the person in charge of training and educational material, and someone familiar with the particular case.
3. Study the event. By answering specific questions on issues, such as whether the event has occurred before, whether the right people knew about it, and if any steps have already been taken to remedy the problem, the team can narrow the list of causes and formulate possible solutions. (A list of relevant questions appears in the box above.)
4. Identify the event's causal factors. Here's where the investigation team begins to answer the "why" question. The team uses structured analytic techniques to discover all influencing factors that contributed to the event. There are two major kinds: direct causes and contributing causes. Direct factors represent the apparent reason. Contributing causes represent process elements and underlying system issues that created the environment in which a sentinel event was more likely to occur. To find underlying system problems or process errors, the team should ask how the event could have been prevented.
5. Select root causes. By systematically analyzing the direct and contributing causal factors, the investigation team arrives at the root causes of an action. Those root causes can include system deficiencies, management failures, unqualified staff, or non-adherence to procedures. There usually are one to three root causes for an event. If you come up with more, investigate further as to why the event occurred.
To make sure you have analyzed the event correctly, check your proposed root causes against questions on a checklist. For each identified root cause, the team should be able to answer "Yes" to all questions. If you aren't able to answer "Yes" to all questions, keep working on root cause identification. (For a sample checklist, see above.)
6. Develop corrective actions and a follow-up plan. After finding the root causes of the event, the investigation team can work on finding workable solutions for root causes. If the event resulted in a serious patient injury or death, the team probably will have implemented preliminary corrective actions. Revisit those knee-jerk solutions to be sure they are the best choices for achieving lasting change.
Team members should work together to review each root cause and generate a list of possible solutions. These actions should be geared directly to the root causes.
Make sure you have a plan for future evaluation, because problems that are "fixed" without a follow-up plan tend to resurface later. Identify qualitative or quantitative measurement data that can be collected during and following implementation. Because sentinel events are rare, don't rely on sentinel event incidence data to measure the success of your solutions. Rather, define measures that evaluate the impact your solutions have on the root causes of the event. For instance, if the root cause was inadequate health team communication, then make sure you measure communication effectiveness.
Once you find something to measure, assign someone to analyze the data.
7. Prepare an RCA report. When you are done, the team should prepare a report that concisely conveys the results of the investigation in a manner that helps the reader understand the event, its chronology, the causal factors, the root cause, and the proposed corrective actions.
RCA complements other performance improvement activities you may do. But finding the root cause doesn't automatically assure that a problem will be rectified. The output must be linked to other components of the performance improvement (PI) process, such as effective project management, error correction, and trend analysis. Although RCA is a vital element in any PI program, it is most effective in conjunction with other program components.
RCA also helps prevent problems as part of a proactive examination of current operations. Identifying and improving high-risk areas or activities can prevent an undesirable event from occurring. To get the most benefit, you should use RCA for reactive and proactive purposes.
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