Root Cause Analysis for a Learning Culture

What is a learning culture?

A quick internet search will tell you that a learning culture puts priority on values, conventions and processes that encourage constant growth and improvement.

Healthcare is a prime example of a learning culture. In fact, according to the Institute for Healthcare Improvement (IHI), having a learning culture is essential to set the stage for healthcare innovation and improvement.

Part of this culture means finding learning opportunities in every situation, including ones where it might be easier to point a finger in blame.

As part of the Webinar Series, Jessica Behrhorst, System Director of Quality & Patient Safety at Ochsner Health System, shared how implementing the Root Cause Analysis and Action framework has helped transform the way the system approaches RCAs. Jessica also shared a quote from Dr. Lucian Leape, who said, “The single greatest impediment to error prevention is medicine is that we punish people for making mistakes.”

The reality is that most mistakes in healthcare do not come down to one person’s actions. Rather, they’re the product of several products and events that, combined, introduced risk into the equation. That’s what makes RCAs such a valuable tool to enable a learning culture.

What’s new in RL6:RootCause?

 The latest version of RL6:RootCause is designed to help healthcare organizations get the most out of the RCAs, regardless of how they conduct them. Some of the core features include:

  • Flexible frameworks. Whether your organization ascribed to the Joint Commission guidelines, RCA2 or a home-grown framework, RL6:RootCause is customizable to suit your needs and processes.
  • Focus on action plans. Organizations can create action plans that address one or more ongoing RCAs in the system to help you get focus on translating your learnings into change.
  • Seamless integration. RL6:RootCause connects with our Risk and Feedback software, keeping all of your information in one place and making starting an RCA seamless.

Learning for the future

Although each hospital or health system might differ in how they conduct their RCAs, it’s all in pursuit of a common goal: learning what happened, why it happened, and what can be done to prevent it from happening again. 

How do you promote a learning culture at your organization? Share in the comments below or join the conversation on HUB.

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