Root-cause software: Look before you leap
Ensure software’s logic is compatible with yours
Your facility probably doesn’t use computer software to handle its root-cause analyses of sentinel events, but odds are good that in the not-too-distant future, the issue won’t be whether to use it, but which software package to choose.
Currently, only about 1% of hospitals use a designated software package to handle root-cause analyses, says Charles Jones, president of Long View, TX-based Decision Systems, maker of the software program Reason. That’s primarily because the leading root-cause analysis software products — some of which have been around for a decade — were developed for use in the areas of engineering, manufacturing, and accident investigation in other industries. Until recently, no one had thought to gear these products specifically to the needs of the health care industry.
"In certain [products], the terminology is so arcane as to be mind-boggling," says Kenneth A. Hirsch, MD, PhD, medical manager for inpatient mental health and continuous quality improvement coordinator for mental health services at the Naval Medical Center in San Diego. The problem is that some of the companies that produce root-cause analysis software "don’t have people who are able to speak medical risk management or medicine," Hirsch adds. "None of the three leaders developed their products in conjunction with anyone who is medically oriented. That doesn’t mean that the processes that underlie [the software] are not good. But it does mean that they do not have a very good understanding of the specific needs of the health care industry. It’s very clear when you open it up and you find terms like latent causality’ and somewhat arcane mathematical terminology, that this isn’t something that the OR nurse is going to make sense out of or even want to."
Further, some of the software systems developed for other industries don’t generate graphics. "That’s a problem, because it means that you then have to use a different program to develop the process flowcharts that the Joint Commission rightly wants to see," Hirsch says.
This state of affairs is already changing, however, as software companies like Decision Systems (Reason), Hopewell, VA-based Reliability Center, (PROACT), and Knoxville, TN-based System Improvements (TapRooT) continue to develop and refine their products for use in the health care industry. (See partial list of root-cause analysis software packages, p. 35.) And despite sometimes steep learning curves, there are a number of advantages to taking an automated approach to conducting root-cause analyses, the developers contend.
For example, Jones says, "At the user level, the procedures and the formats that produce accurate data are geared into and imbedded in the software, so that using a software [system] tends to guide and to filter out erroneous information." Jones adds that software can also help in "transferring knowledge" to other staff members. "If you have software in-house, several people can leave your organization, but by using the same software, they’ll find that there’s continuity in the reporting and in the data, because it’s imbedded in the software itself."
Also, root-cause analysis software stores information electronically, allowing for easier access. "And if it’s tied into a proper kind of lessons learned’ system, it provides a wonderful resource for data, so that mistakes made in the past need not be repeated," Jones says.
"Basically, it gives you a standardized process," Hirsch adds. "Anytime you have a standardized process for anything, it means that you then have some organization. You can control the process and make sure that it meets the criteria that you as an organization have established."
Software can guide disparate personnel
Also, in many facilities, no one person has full-time responsibility for conducting root-cause analyses. "You’re going to have practitioners, clerical people, security guards, logistical personnel, and others — people with jobs that have nothing to do with a root-cause analysis," says Hirsch. "And while it’s possible to conduct a root-cause analysis with an effective team leader and facilitator, "good software will guide the team as a whole in how it should conduct a root-cause analysis. It will tell them what tools to use and when to use them."
The advantage of this, Hirsch says, is that once a facility starts doing root-cause analyses well, it tends to do more and more of them. "The threshold for doing them drops, and the reason is that it’s a very value-added process or endeavor."
Even so, it’s important to note that there are also potentially serious drawbacks to taking an automated approach to root-cause analysis. First, the logic structure — the set of assumptions and values that underlie an individual software program — might not square with your own ideas (or the Joint Commission’s) of how a root-cause analysis should be conducted and what factors should be considered.
"If one is going to judge the value of a software root-cause analysis product, you have to know what the process is that it utilizes," Hirsch stresses. "Some are going to be good, and some are going to be bad. If you happen to buy a software root-cause analysis tool or product that is based on a not-very-good analytic process, the quality of your analysis is going to be poor." Hirsch adds that it’s easy to be taken in by a software tool that "looks good and feels good" to use. "But if it doesn’t have a good process, it will give the illusion of having led a team through an effective analysis when in fact it has not done so."
The solution, Hirsch says, is to ask this question: If you were to conduct a root-cause analysis manually using the procedure contained in the program, would you be comfortable in the belief that you had achieved a good-quality analysis?
Will JCAHO give a seal of approval?
As root-cause analysis software enters the mainstream in health care, some experts already have begun clamoring for some type of certification program to help establish uniform standards for what the software should include. Inevitably, that discussion has centered primarily on the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations, whose sentinel event policies opened the gate for the introduction of such software in the health care industry. Jones acknowledges that his company at one point had engaged in talks with the Joint Commission about some sort of relationship, but he doubts anything will come of it.
That’s good news to Hirsch, who recently unveiled his own software package, Root Cause Analyst. He says, "If the Joint Commission were to sign a contract with any software developer, we’d probably sue. They’d be establishing a mandate and then partnering in the development and marketing of a software product designed to meet that mandate, and that smacks of conflict of interest."
A better approach, he says, would be for the Joint Commission to establish criteria by which to evaluate all root-cause analysis software products. "Then all of them could compete, and multiple ones could be endorsed," Hirsch says. "That would be very legitimate, but they should have no pecuniary interest in any of them."
Whether or not your facility chooses to go with root-cause analysis software in the near future, Jones and Hirsch agree that it would do well to build uniformity and standardization of procedures into its root-cause analysis process. "So often, we see people using concepts that are nothing more than somebody’s opinion, based on brainstorming or group voting, and while all of those systems have some advantages in employee involvement and things of that nature, they usually provide inconsistent and misdirecting information," Jones says. "In my opinion, the health care industry must not fall into the trap of using processes and approaches that are subjective, because people’s lives are on the line."
(Editor’s note: Next month, we’ll follow up with specific advice on how you can choose the root-cause analysis software product that’s right for your institution.)
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