Conduct a cost-effective RCA by brainstorming
Pre-emptive SE approach avoids crisis functioning
By Kenneth A. Hirsch, MD, PhD
Dennis T. Wallace, DABRM
If your institution experiences a sentinel event (SE) without a formal process of root-cause analysis (RCA) in place, you’re in a position of crisis functioning — and on your way to losing an expensive battle.
Bear in mind that the Joint Commission expects a gradual development of processes for conducting RCAs. The better scenario is the pre-emptive approach. Practice your RCA on non-sentinel events. One hospital conducted an RCA for training purposes on a simple patient fall that had no real adverse outcome, and it ended up saving the facility about $525,000 in direct costs and an unknown amount in prevented litigation incidents.
As you proceed, keep in mind how the Joint Commission will judge your analysis. The agency has not yet clearly articulated the criteria by which compliance with standards will be measured, but it does respond well to a facility that conducts RCAs on non-sentinel events as well as SEs.
Here is one way to conduct an RCA. Data indicate that using this process costs approximately a third of other team-based processes, with no reduction in its "thoroughness and credibility" or value.
First, define and disseminate information throughout your organization regarding what constitutes an SE, and identify that one has occurred. Designate who is to be notified and how, as simply as possible. You want people to report to you, not to the newspaper or the Joint Commission. Thank them, and make certain they get feedback when the RCA is completed.
If an RCA is deemed appropriate, choose an RCA facilitator (the process expert) and a team leader (the content expert). They sit down and identify:
• what data have to be safeguarded — medical records, statements from personnel, maintenance records, instruction manuals, policy manuals — and who should do it and how;
• who should be on the team. It is better to be over-inclusive than under-inclusive. Invite every person in the involved department(s) to every RCA, regardless of each person’s involvement in the SE itself. Notify each invited person to bring with them a written (and electronic) sequence of everything they observed and ideas they have.
Three or four meetings one week apart of no longer than two hours each are generally sufficient for a worthwhile RCA, with allowance for additional time spent between those meetings by selected participants. Encourage an active interplay between the facilitator and the team leader. Have someone take notes, and have a display board and computer-projector if possible.
Explain RCA’s focus on systems
A good way to begin is to explain that "we are here to find out all we can about the event — how it happened and how it might be prevented in the future." Emphasize that the purpose is not to find fault with providers. The focus should be directed toward the systems and processes that could have contributed to the event’s outcome in order to prevent future mishaps. Put people at ease by presenting an example of an RCA in which it appeared at first that specific persons were at fault but in the end it was demonstrated that a series of system failures were the cause.
Block off part of the display board as a "parking lot" in which to write items that don’t apply now, but should be remembered. Start by generating the sequence of events, and people will start suggesting causes and solutions. Write them down in the parking lot, avoiding discussion of anything but the event sequence for now. Make the sequence detailed and complete. Identify the corrective actions taken at or near the time of the event.
Have the team look at the sequence, and mark every item that might in some way have contributed. Brainstorm. Let the group come up with any and all ideas about events, conditions, or anything that might in some way have contributed to (not caused) the adverse event. Use the parking lot to record ideas that are solutions, as well as ideas that may be incidental but may yield other opportunities for performance improvement. Consult the Joint Commission’s manual, Conducting a Root Cause Analysis in Response to a Sentinel Event, for a list of possible contributors common in SEs, and use those items as prompts.
Eliminate duplications, combine items, and form logical clusters from the brainstorm items. When everyone is reasonably satisfied with the process, the first meeting ends. During the intervening week, the team leader and facilitator meet and develop a "Contributory Factor Diagram" from the material generated by the team. This inverse-tree format flowchart contains names assigned to each cluster. Under each cluster name, in parallel so that equal weighting is implied, lies every member of that cluster. Move clusters around to see if one subsumes another. (Good flowcharting software is an assist here.) Look at each item and ask "why" or "how?" Ask these questions five times for each "branch" or item.
You may identify areas of insufficient data, or you may be able to place new items at other levels. Your goal is to go as far as possible with the facilitator and team leader asking the question "why?" ("drill down") until it can no longer be meaningfully asked or answered. Code each of the bottom items of every branch as "Insufficient Data," "Non-Contributory," or "Contributory," and color/shape code those three categories. (See Contributory Factor Tree, p. 111.) Assign people to get the missing data before the next team meeting.
At your next meeting, ask for the team’s input on your flowchart. Let them check for omissions, better organization, and more logical flow, and let them generate alternatives. See if they can ask the question "why?" in different ways. By the end of an hour, there should be few or no Insufficient Data labels. Make certain every factor labeled "Non-Correctable" is in fact so. Every "Contri bu tory Factor" that has no lower-level derivative is a root cause, but avoid that terminology for psychological and legal purposes.
In the most formal quality improvement sense, "Non-Contributory" items should not appear in your RCA. But certain of these items will be so high-visibility that you must mention them just so reviewers — either internal or external (such as the Joint Commission) — know they were considered. You have now completed the RCA.
Now, for the action plan: Have the team generate at least one corrective action or improvement for each "Contributory Factor." In some cases, that action will be to recommend that hospital administration designate a working group to address a specific issue.
Develop an RCA reporting table or grid with columns for:
• contributory factor;
• corrective action;
• person(s) responsible;
• action due date;
• measurement strategies;
• person(s) responsible for monitoring measurements;
• follow-up date.
At the third meeting, present to the team the event sequence, the contributory factor diagram, and the RCA reporting grid.
Ask for feedback and changes, especially in the area of additional opportunities for improvement. Identify who should receive copies of the entire work. At a minimum, communication should include the heads of involved departments, all involved persons, the office of risk management, and the office of continuous performance improvement. We recommend that senior administrative management and senior medical staff officers review the work product to enhance its credibility. In addition, discuss the findings with the person who reported the event.
It is the obligation of the continuous improvement department to monitor progress made in the corrective actions proposed and to appraise the measurements used to evaluate those improvements. The department must have established suitable processes to ensure that there is appropriate follow-through in accordance with the action plan.
Joint Commission reviewers have given good feedback on RCAs conducted using this approach.
[Editor’s note: Kenneth A. Hirsch, MD, PhD, is president of Medical Risk Management Associates LLC, 4572 Delaware St., San Diego, CA 92116. Telephone: (877) 816-6594 (toll-free) or (619) 532-8564; Web site: www.sentinel-event.com.]
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