Root Cause Analysis and Risk Reduction Action Plan Summaries

Page Contents: What is RCA? | When should RCA be undertaken? | What are the timelines for RCA? | RCA investigation principles | Attributes of a RCA investigation | Major steps in a RCA investigation | Commissioning a RCA investigation | Writing root cause statements | The five rules of causation | Preparing recommendations and reports | Writing a RCA report | Post-RCA investigation responsibilities | Developing the risk reduction action plan | RCA document management | Department of Human Services reporting requirements |

What is RCA?

RCA is a process analysis method, which can be used to identify the factors that cause adverse events. The RCA process is a critical feature of any safety management system because it enables answers to be found to the questions posed by high risk, high impact events—notably, what happened, why it occurred, and what can be done to prevent it from happening again.

Risk managers and other health care personnel use RCA analytical methods to investigate (‘drill down’ into) serious incidents (including near misses) to identify the underlying causes and to guide solutions to address safety system failures.

When should RCA be undertaken?

RCA is normally only performed on high risk, high impact events, such as sentinel events. In 2004–05, the Department of Human Services included the requirement for health services to report ‘near miss’ sentinel events as part of the reporting requirements for the sentinel event program. In this program, a reportable near miss sentinel event is managed using the same processes as an actual event.

The RCA process should not be performed for incidents involving criminal acts or requiring disciplinary action.

What are the timelines for RCA?

The RCA processes should be instigated as soon as practical after an incident. The more time elapsed, the less reliable the account of events by people involved and important information might no longer be available.

• A RCA team should be convened within two working days of the incident occurring.
• The RCA report should be signed off within 2 calendar months of commencing the investigation.

Public hospitals and public health services are funded by the Department of Human Services on the condition that they will:

• notify the department of the occurrence of all sentinel events by completing the sentinel event notification form
• report investigation findings and submit a risk reduction action plan within 2 calendar months to the Department of Human Services.

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RCA investigation principles

The main principles of a RCA investigation are to:

• focus on systems and processes, not individual performance

• be fair, thorough and efficient

• focus on problem solving

• use recognised analytical methods

• use a scale of effectiveness to develop recommendations.
  

Attributes of a RCA investigation

The four major attributes of a RCA investigation are:

1. thoroughness: a complete review of all possible causes is required
2. fairness: in terms of involvement of all staff associated with the incident
3. efficiency: the time taken to undertake the investigation should be consistent with the significance of the problem being investigated
4. independence: including independent team members will reduce the impact of bias and overcome the fear of having to present information others might not want to hear.

Major steps in a RCA investigation

The major steps in a RCA investigation are:

1. verify the incident and define the problem
2. commission the RCA investigation
3. map a timeline (event and causal factor chart)
4. identify critical events
5. analyse the critical events (cause and effect chart)
6. identify root causes
7. support each root cause with evidence
8. identify and select the best solutions
9. develop recommendations
10. write and present the report.

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Commissioning a RCA investigation

The ultimate responsibility for responding to serious incidents lies with an executive position with primary responsibility for the delivery of clinical care. This might be the chief executive officer or the director of medical services or director of nursing services. This individual becomes the executive sponsor for the RCA program.

Verifying the incident and defining the problem

To brief the commissioning executive and focus the RCA effort, the RCA coordinator must first define and determine the level of significance of the problem that is to be investigated.

Defining the problem provides a clear understanding of:

• the problem the RCA team is required to address

• the scope of the investigation

• the consequences of the incident.

Forming the RCA team

A small group of staff, which has expertise either in RCA methodology or in an area relevant to the incident, conducts the RCA investigation. Organisations should try to keep the size of the team manageable: between three and six members is ideal.

A RCA facilitator is responsible for facilitating the RCA investigation. This includes forming the team, mapping the event, ensuring the team meetings occur and follow the agreed process, and facilitating team meetings. This person might also be the RCA coordinator.

A RCA team leader is usually the head of a clinical unit or another staff member with a recognised leadership role. Their role involves ensuring clinical participation, supporting the team facilitator at meetings, and ensuring the clinical content is relevant and appropriate.

RCA team members are these staff who participate in the team meetings and assist with data gathering. They provide relevant expertise and should be able to provide impartial input.

Organisations should only involve staff who were directly involved with the incident if their ability to remain objective is not compromised.

Team members do not need to be clinical staff. Organisations should involve staff who are familiar with work practices and systems (for example, biomedical engineering, security, consumer liaison, and administrative staff).

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Writing root cause statements

Root cause statements

Root cause statements are written as conclusions. Conclusions can be either:

• cause and effect statements
• prophetic statements (predictions).

An example of each is given here.

Cause and effect:

The lack of staff training on the management of patients with chest pain resulted in the patient being discharged without appropriate investigations being completed, which contributed to the patient’s readmission and subsequent cardiac arrest

Prophetic:

The unavailability of guidelines for the management of chest pain in the emergency department will continue to contribute to the delivery of sub-optimal care.

The five rules of causation

1. Causal statements must clearly show the ‘cause and effect’ relationship. When describing why an event has occurred, show the link between the root cause and the undesirable outcome.
2. Negative descriptors are not used in causal statements. To force clear cause and effect descriptions (and avoid inflammatory statements) do not use negative descriptors.
3. Each action cause must have a corresponding conditional cause. For every human error in the causal chain, there must be a corresponding condition cause that combined to contribute to the undesired effect.
4. Each procedural deviation must have a preceding cause. Identify the cause of a procedural violation, not the violation.
5. Failure to act is only causal when there was a pre-existing duty to act. The duty to perform might arise from standards and guidelines for practice or other duties to provide patient care.

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Preparing recommendations and reports

Formulating recommendations

The investigation team writes recommendations after the solutions have been evaluated for the likelihood of their effectiveness. Recommendations are suggested actions which management will consider after the investigation report has been presented to the executive sponsor.

The RCA team will need to consider who to consult when developing recommendations and be aware of the wider system implications of actually putting recommendations in place.

To be credible, recommendations should be evaluated against:

• the root cause (conclusion) statement
• the RCA method used
• the level of associated risk
• the hierarchy of control
• achievability
• the perceived value to the organization

Writing a RCA report

Reports are written to communicate to management the findings, conclusions and recommendations pertaining to the initial problem the RCA team was requested to investigate. The report is written after recommendations have been evaluated for effectiveness.

Regardless of the reporting format chosen, the report should include these three elements:

1. executive summary
2. event and causal factor chart
3. conclusions, supporting evidence and recommendations.

The report’s comprehensiveness depends on the significance of the investigation findings.

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Post-RCA investigation responsibilities

After signing off the RCA report, it is the executive sponsor’s responsibility to develop and implement a risk reduction action plan to manage the risks identified by the RCA team.

The RCA program coordinator has responsibility for:

• arranging for the findings to be presented to the people involved in the incident
• ensuring organisational reporting requirements are met
• completing Department of Human Services reporting requirements.

The sponsoring executive is responsible for:

• ensuring a risk reduction action plan is prepared and implemented
• monitoring the progress and outcomes of risk mitigation strategies

Developing the risk reduction action plan

The causal statements developed in the RCA investigation need to be converted into risk statements. This should be done in conjunction with staff responsible for organisational risk management. It requires an assessment of the level and analyses of the risk.

The risk reduction action plan should include a description of:

• who is accountable for the risk
• what action is to be taken
• who is responsible the action
• when the action is to be completed by
• a measurable performance target.

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RCA document management

Keeping a RCA investigation register will provide a record of the investigations undertaken, when they were done, what problem they were commissioned to solve, and which staff participated.

Keeping a copy of all completed reports, risk reduction action plans and the outcomes achieved is necessary in case a similar problem occurs and the organisation needs to identify which strategies were ineffective.

Documenting risk reduction action plans in a risk register or other action tracking system is necessary to ensure the monitoring and outcome loop is closed.

Note: If investigations were not protected by legal or professional privilege, all documents are subject to disclosure.

Department of Human Services reporting requirements

Sentinel event notification

Public hospital service agreements require Victorian public hospitals to notify the Department of Human Services of the occurrence of all sentinel events. Notification should be sent to sentinel.events@dhs.vic.gov.au

For a copy of the department’s notification form, visit the sentinel events reporting page.

On receipt of initial notification, the department will provide the hospital with a sentinel event reference number to be indicated on the root cause analysis, risk reduction action plan summary and other correspondence about the episode.

These forms are available electronically at the sentinel events reporting page.

Any queries regarding the above can be directed to the Program Manager on telephone: (03) 9096 7916 or by e-mail to sentinel.events@dhs.vic.gov.au

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