Root Cause Analysis

1
Root Cause Analysis Training for HCAI
2
Session 1 Welcome and Introductions
3
RCA for HCAI Programme
Session Session Timing (mins)
1 Introduction 15
2 RCA Context and Overview 15
3 RCA Process 20
4 RCA Tools 25
Coffee 10
5 Role of the RCA Review Team 25
6 Analysis 55
7 Summary and Evaluation 15
4
Session 2 RCA Setting it in context An
introduction to RCA
5
RCA Introduction Context

• What is it?
• A retrospective review of a service user safety
  incident undertaken in order to identify what,
  how, and why it happened
• A process of investigation and analysis is then
  used to identify areas for improvement.
• Finally recommendations and sustainable solutions
  are agreed to minimise the recurrence of the
  incident type in the future.

6
RCA Introduction and Context

• When should RCA
• be undertaken for HCAI?

7
When should RCA be undertaken for HCAI?

• All MRSA bacteraemia
• Local consideration to CDI cases that may
  include
• CDI Deaths
• End stage disease e.g. colectomy
• Outbreaks
• Cluster
• Other infections as per local policy

8

• Benefits of RCA
• for HCAI?

9
Benefits of RCA ?

• Service User
• Reduced risk of infection, increased safety and
  quality of care
• Improved service user choice
• Increased Public confidence
• Providers of Care
• Improved quality and safety, focus on risks and
  contributory factors, ability to target
  resources, improved service user pathways,
  increased service user confidence, shared
  learning
• Reduced length of stay
• Reduced litigation
• Improved staff moral
• Commissioners of care
• Improved assurance, governance, education,
  communication, clinical practice, shared learning
• Improved ability to commission quality care
• National
• Reduced infection rates, reduced political focus,
  development of tools and guidance,
• increased public confidence

10
Session 3 RCA Process
11
A Clear Process for HCAI

• React
• Identify immediate care needs
• Commence treatment and management of bacteraemia
• Identify any obvious problems and take action
• Record
• Gather data
• Map the patients journey
• Arrange RCA review meeting to identify problems,
  contributory factors and root causes
• Agree action plan
• Respond
• Deliver action plan
• Monitor action plan delivery and impact
• Identify act upon organisational themes and
  trends

12
RCA for HCAI Best Practice Process

• Organisations encouraged to perform gap analysis
  against process
• Aiming to embed HCAI prevention into everyday
  culture
• Guidelines intended as a benchmark for local
  interpretation and action to improve on their
  existing process rather than replace it

13
Process
14
Session 4 Root Cause Analysis Data Gathering Tools
15
MRSA Data Gathering Tool
16
How to use the tool

• RCA Lead completes the data gathering tool prior
  to the formal RCA review meeting
• The tool is sent to participants in advance of
  RCA review meeting
• RCA Lead maps the data to aid analysis at the
  review meeting

17
Session 5 Role of the RCA review team
18
Purpose of the RCA Review
19
Purpose of the RCA Review

• Analyse the data gathered
• Identify problems in the care pathway
• Identify contributory factors
• Identify root cause
• Identify actions to prevent recurrence

20
RCA Review

• Who should be involved ?

21
Who should be involved ?

• Core Team
• RCA Lead
• Executive lead
• DIPC
• Microbiologist / Infection Control Doctor
• Infection Control Practitioner
• Admin Support
• Risk/Performance Manager
• Matron / Senior Nurse
• Care setting representatives
• Doctor responsible for management of patient
• Nurse responsible for care of patient
• Others as appropriate

22

• Analyse the information
• Contribute to analysis of human and other
  contributory factors
• Analyse underlying systems and processes through
  a series of why questions

• Validate the data
• Review RCA paperwork in advance of meeting
• Contribute to the discussions to validate the
  information and data
• Challenge assumptions

Roles and Responsibilities Of The RCA Review
Team

• Learning the Lessons
• Communicate findings through local staff
  bulletins and team meetings
• Demonstrate leadership and recognition of the
  seriousness of HCAIs to all clinical staff
• Ensure outcomes and actions are implemented
• Escalate unresolved issues to management team
• Educate staff to ensure new practices are
  sustained

• Develop an action plan
• Provide an expert contribution to the
  validation of the key issues/ emerging findings
• Make recommendations and agree actions that
  relate to the most fundamental cause(s)

23
Verifying the data

• RCA Lead checks the findings from the initial
  data collection exercise to ensure there are no
  gaps and all unconfirmed data has been confirmed
• RCA Lead presents the findings in a logical order
  to the group
• RCA team identifies the key issues/problems
  within the findings
• Using a process of brainstorming
• Capture initial thoughts of the team
• Prioritise in order of importance
• Asking the right question is at the heart of
  effective RCA process
• This will help to ensure you gather useful
  information and learn more

24
Identifying Problems

• Simple definition
• Something happened that should not have
  happened
• ..or something should have happened, but didnt.

25
Describing your problems

• To effectively analyse problems, a specific
  description of what happened is required
• Be specific not vague
• Communication failure X
• Nurse failed to inform doctor of wound condition
  OK
• Identify what happened not why
• Inadequate training on hand hygiene X
• SHO did not wash or decontaminate his hands OK

26
Analysis of findings

• Once the problems have been identified the review
  team needs to
• Analyse the key issues/problems
• Drill down to unearth the contributory factors
  and ultimately the root causes
• Reach agreement on the root cause
• Use tools such as Five Whys and the cause and
  effect diagrams to help explore the contributory
  factors of each problem
• Tools are designed to encourage more in-depth
  analysis at each level of cause and effect

27
Five Whys Technique
Nurse failed to undertake MRSA screening on
admission
Why?
She was not aware this was a requirement for
emergency admissions
This was not covered in her orientation to the MAU
Why?
Why?
IPC was not included in the induction training
for new starters
Why?
No Registered Provider wide approach to ward
induction programmes
Root Cause
28
Identify Root Cause(s)

• What is a Root Cause?
• A fundamental contributory factor which, if
  resolved, will reduce the likelihood of
  recurrence of the identified problem.
• There may be more than one root cause and
  therefore the RCA team must identify the
  contributory factors which have the greatest
  impact on each problem.
• Using the Five whys technique will help
  identify the most significant contributory
  factors.

29
Confirming action plan and follow through

• Chair will lead the discussion on identifying
  actions to be undertaken to
• Address the root causes
• Highlight the outputs of each action
• Outline the timescales for delivery
• Identify the responsible owner
• Decide what can be done to prevent the problem
  happening again
• Explore how the solution will be implemented
• Agree who will be responsible/accountable
• Agree what are the risks of implementing the
  solution

30
Session 6 Analysis
31
Analysis

• Who needs to be present at the review meeting ?
• Is there any data missing?

32
Participants at the review meeting?

• RCA Lead
• Consultant in charge of patient
• Matron/s
• Ward Managers
• Junior Doctors
• ICN

• Microbiologist
• Pharmacist
• Locality Manager
• District Nurse/s
• PCT Manager
• GP

33
Is there any data missing?

• Community screening policy
• AE record
• Staff training records - PCT
• Staffing levels
• Process for blood culture taking
• Bed management data
• side room use and time to isolation

34
Group Activity

• Discuss and Identify
• Problems
• Risks to Other Patients
• Contributory Factors
• Root Causes

35
Findings Pre Hospital
Activity Identified Problems
Long term management of catheterised patients No systematic review of care needs or referral for review No engagement of continence teams or urology links despite service user requests and ongoing catheter problems No detailed plan for long term supra pubic catheter care and type of catheter used No MRSA risk assessment undertaken MRSA screening was not carried out although service user was high risk (previous admission to ICU in Spain).
36
Findings Pre Hospital
Activity Identified Problems
Routine change of supra pubic catheter No plan of care for known difficult/traumatic supra pubic catheter change Sensitivities to catheter products not effectively communicated No antibiotic cover to reduce the risk of infection following traumatic catheterisation. Previous problems with haematurea.
37
Other factors Pre Hospital
Activity Contributory factors
Documentation Poor legibility Lack of chronology and significant gaps in the records
38
Delayed diagnosis of MRSA Hospital
Activity Problems to be addressed
Screening Isolation Decolonisation Antibiotics No MRSA screening on admission despite high risk Delay despite diagnosis with MRSA Bacteraemia 18 hour delay in isolating service user (including multiple bed moves) No evidence of cohorting in the intervening period No evidence of ICN engagement 24 hour delay in commencement of decolonisation 24 hour delay in starting IV antibiotics Unclear prescriptions on drugs chart
39
RCA Review

• What are the root causes?

40
Session 7 Summary
41
RCA for HCAI

• Further Reading
• Towards Cleaner Hospitals and Lower Rates of
  Infection
• 7 Steps to service user Safety
• Anderson, Bjorn Fagerhaug, et al (2000) Root
  Cause Analysis Simplified Tools 7 Techniques ASQ
  Quality Press.
• National Confidential Study of Deaths Following
  Meticillin-Resistant Staphylococcus aureus
  Infection. London Health Protection Agency,
  November 2007
• Useful Websites
• http//www.hpa.org.uk
• http//www.npsa.nhs.uk
• http//www.dh.gov.uk