Running an effective root cause analysis (RCA) is an ongoing challenge for healthcare organizations, however recent research has generated new insights on ways it can be optimized.
Traditionally, an RCA process consists of an investigation of adverse events and unsafe conditions, that generates learnings and an action plan to prevent their occurrence in the future. Previously, frameworks for RCAs have led to inconsistent results, which is why the NPSF has recently proposed a Root Cause Analysis and Action (RCA2) framework, supported by The Joint Commission (TJC). This model puts the focus on the actions taken once an investigation is completed.
To go one step further, the healthcare industry is embracing learnings from High Reliability Organizations and incorporating two tools to support teams performing RCAs: The Human Factors Analysis and Classification System (HFACS) and the Human Factors Intervention Matrix (HFIX).
Human factors analysis and intervention: how does it apply to RCA?
According to a report released by TJC, human factors analysis (also referred to as human factors engineering) is an essential step to designing equipment, procedures, tasks and work environments because human involvement is a factor in 80 to 90 percent of errors.
This approach considers each layer of the system and environment is considered when investigating an event. The goal here is to understand that humans are fallible and that errors are to be expected - rather than assigning blame to one individual. Ultimately, the focus is assessing and addressing the conditions that contributed to the error in the first place.
In order to account for all of these layers during an RCA process, an HFACS analysis is performed at the same time that organizations conduct their usual fact-finding and causal statements steps of the RCA.
The HFACS analysis encourages organizations to look at the event on four different levels:
- Unsafe acts: This section is divided into errors and violations. Errors refer to when the person was training incorrectly or didn't know the process. Violations are when a person knows what the process is, but decided to perform it differently for various reasons.
- Precondition for unsafe acts: This layer looks at why these unsafe acts were performed, looking at individual factors, including the person's mental state at the time, situational factors, tools and technology utilized during the event, and team factors which look at communication and leadership within the team.
- Supervisory facts: In this layer, the people who are in charge of the preconditions and their leadership are investigated. This tends to be relevant when there is an un-engaged supervisor who is not addressing hazards and violations.
- Organizational influences: This layer connects back to the organization's culture, processes and resource management.
Once you complete the investigation, HFIX comes into play. At it's core, HFIX is about generating out-of-the-box ideas to prevent errors from reoccurring, which are collected and encouraged during brainstorming sessions.
When the brainstorm is complete, the ideas are ranked from 1 to 5 based on five factors:
The final output is a matrix that helps you and your organization choose a best course of action - as well as grounds to support your ideas during presentations to leadership.
An ongoing journey
At ASHRM 2017, Adventist Health System presented on how they use these concepts in their RCA process. Their team was tasked with implementing a system-wide process to improve patient safety, after the analysis of closed claim data that indicated vulnerabilities in their old process.
Working with aviation partners, they developed a model to infuse the HFACS and HFIX methodologies into the RCA2 framework. The result was a 14-step model and interactive document that guides the entire organization through the RCA process. Combined, these changes empowered each site to conduct their own investigations.
While this is still an ongoing journey, the new process allows reams to dig deeper into what circumstances caused an event and develop effective strategies to prevent events by thinking outside the box.
How do you conduct your RCA process? Let us know in the comments below - and keep the learning going.
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