Conducting A Root Cause Analysis

Nina Shik, MSN, RN, NEA-BC, CICDirector of EpidemiologyNorth Shore University HospitalManhasset, NY

NSUH is an 804-bed quaternary teaching hospital in Manhasset, NY. NSUH is a Level 1 Trauma Center with 5 Adult ICUs and a Level-3 NICU.

It is the largest hospital in the North Shore-LIJ Health System.

North Shore University Hospital

My Role• 22 years of experience in Infection Prevention• Director of the NSUH’s Infection Prevention

program since November 2012• Report to Hospital’s Associate Executive

Director of Quality and System VP of Infection Prevention

• Lead a team of 6 Infection Preventionists• Work with IPs from across the NS-LIJ System

Root Cause Analysis (RCA)

• RCA is a systematic, formalized approach to review an adverse event and identify root causes

• RCA provides a forum for key individuals to:– focus on a problem– come to consensus about factors leading to

the problem– develop effective corrective actions

Root Causes• Specific factors leading to adverse events• Help identify what, how and why an event

occurred• Are specific and based upon factors that can

be modified• Identifying “snow storm” as the reason staff

were not available to provide patient care is not specific enough. We can’t control the weather.

Not a “Stand Alone” Solution

• RCA is a strategy that complements other quality improvement activities

• RCA is most effective within a comprehensive safety program

RCA Steps• Develop a core team that is invited to every

RCA. For an HAI RCA this includes:– Chief Medical Officer, Associate Executive Director

of Quality, Infection Preventionists, Infectious Diseases Chair and the Medical and Nursing Directors for area being reviewed

• For each meeting invite other participants depending on type of issue being addressed – Always include care providers who were involved

in event– Cast a wide net

Before the RCA Meeting• Outline a step-by-step process leading up to, during

and after the RCA meeting, including:– Who leads the meeting– Who takes minutes– Who provides patient information during the RCA and

what information they are expected to share– Who researches and shares applicable standards for care– Who develops action items, based upon root causes– Who implements the action items– Who collects data to determine efficacy of interventions– How to determine if interventions are effective

Before our Meetings• IP identifies HAI, based on NHSN definitions• Nurse Manager review patient record to

determine who should attend RCA • IP Director contacts the attending physician

and Chair of Infectious Diseases to discuss the event and the RCA process

• IP Director sends list of meeting participants to Quality Department

• Quality organizes the meeting and invitations

During our Meetings

• Chair of Infectious Diseases chairs the meeting• Attending Physician presents the patient’s

case • Infection Preventionist presents the HAI

history• Care providers present patient-specific HAI

clinical information• The group discusses the case and identifies

causative factors

At the End of the Meeting

• The Chair summarizes discussion points• The group determines action items• The action plan is written down• Goals are established (e.g., decrease CAUTI on

the unit by 50% in the next 3 months)• Data collection method is determined• Follow up time frame is established

After the Meeting

• Action plans are implemented• Follow-up data are collected• Data are reviewed and share with key players

and relevant committees• If results are positive we may decide to spread

the interventions to other units• If results are not as hoped we conduct

additional RCAs

Getting to the Root Cause

• Make sure that the right people are in the room

• Ensure a safe, non-punitive environment• Start with an overview of the processes

related to the event• Focus on issues, not individuals• Let everyone provide input, but keep the focus

on the event and related processes.

Questions to Consider• What happened?• When and where did the occur?• What are usual, recommended

processes/practices for this type of care/device/procedure?

• Were all steps followed, in the correct order?• Were all providers trained and competent?• Are there other factors to bring up?

Helpful Tools

• Fishbone diagram is helpful to keep focus on evidence-based risk factors.

• Fishbone “spines” often include:– Patient-specific factors– Caregiver factors– Equipment factors– Environmental factors– Systems factors

Pre-populated Fishbone

• If factors contributing to a problem are well defined in the literature it may be helpful to use a prepared Fishbone Diagram that includes these factors

• Contributing causes of CAUTI are well-recognized, so we use a pre-populated Fishbone for CAUTI RCAs that IPRO provided

• It ensures a consistent review and consideration of all relevant risk factors

IPRO CAUTI Fishbone

“5 Whys” of Problem Solving

• Using 5 Whys helps us to think beyond obvious “gut feeling” aspects of a problem to get to root causes

• Allows different ideas to be expressed• Encourages every participant to provide input

“5 Whys” Example• Why do you think the CAUTI occurred?

– The catheter was left in longer than needed• Why?

– An order to remove it was not written• Why?

– The nurse and doctor forgot to discuss the need for the catheter during rounds

• Why?– Their rounding tool does not address urinary catheters

• Why?– The tool was just revised and the urinary catheter daily

assessment section was inadvertently deleted

Action Plan• You may identify several root causes• Suggestions for improvement should be

discussed for each one• By the end of the meeting a list of action items

should be developed, with identified “champions” and a time line for completion

• Some items may need to be addressed by a smaller working group or hospital administrators

Support and Follow-Up• A high level of energy usually occurs after a

successful RCA • Staff are motivated to make identified changes

– Provide resources to support them– Collect data to determine if the changes are

effective– Share data with RCA participants– Celebrate successes!

Benefits of RCAA successful RCA program:• Increases collaboration and sharing of

information• Allocates resources to meaningful root causes• Encourages accountability and follow-up on all

levels• Identifies solutions to share with other areas

of your facility/system• Promotes a culture of safety

NSUH CLABSI RCAs• Part of a comprehensive CLABSI prevention

initiative• Rates decreased, but did not reach zero until

RCA’s were formalized and expanded to include more physicians

• At a recent luncheon to celebrate zero CLABSIs our Chair of Infectious Diseases remarked that the best thing about zero CLABSIs, in addition to patient benefits, was not having to attend RCA meetings!

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12Jul-1

2

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13Jul-1

3

Aug-13

Sep-13

0

1

2

3

4

5

6

7Numbers of CLABSI by Month

RCA process formalized

RCAs began

RCA member-ship expanded

References

• Rooney, J. J., & Heuvel, L. N. V. (2004). Root cause analysis for beginners. Quality progress, 37(7), 45-56.

• Zidel, T. G. (2006). A Lean toolbox: Using Lean principles and techniques in healthcare. J Healthc Qual, 28(1), W1-7.

• IPRO Root Cause Analysis Toolkit qio.ipro.org/wp-content/.../12/7_1-12-14_RCA_Toolkit_final.pdf

Questions?

?Thank you for your attention

I can be contacted at nshik@nshs.edu