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Problem Solving for Root Cause Analysis

An overview for CLARION Case Competition 2009

Presented by: Sandra Potthoff, Ph.D.

Director of Program in Healthcare Administration

School of Public HealthUniversity of Minnesota

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CLARION Case• Description of Organization

Overview of Hospital and broader environmental context

• Topic Detailed description of care delivered to a patient that lead to a sentinel event

• Team Assignment Conduct a root cause analysis and present your recommendations and implementation plan for system changes to an interprofessional panel of judges

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SENTINEL EVENT

• An unexpected occurrence involving death, serious physical or psychological injury, or risk thereof

• Occurrence results from a variation from the desired process

• Variation can have a common cause, special cause, or both

Joint Commission (2003). Root Cause Analysis in Health Care: Tools and Techniques, 2nd Edition.

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HUMAN ERROR

“Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects… Their part is adding the final garnish to a lethal brew that has been long in the cooking.”

James Reason (1990) Human Error

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VARIATION

• COMMON CAUSE: variation that occurs in processes because of the way a process is designed; typically at the blunt end of the system

• SPECIAL CAUSE: variation that occurs because of unusual circumstances in the process, for example, human error; typically at the sharp end of the system

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SHARP END

BLUNT END

ORGANIZATIONAL CONTEXT

Resources and Constraints

Operational System as Cognitive System

Errors and Expertise

Cook and Woods (1994) Operating at the sharp end: the complexity of human error

Human Error and Medicine

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PROBLEM SOLVING PROCESS

PROBLEM DEFINITION

ROOT CAUSE ANALYSIS

RECOMMENDED SOLUTIONS

IMPLEMENTATION

What happened?

Why did it happen? (get to 5th order why)

How can this be prevented from happening again?

Are solutions fixing the root causes?

Who and how

Time and budget

Ongoing monitoring

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PROBLEM DEFINITION

ROOT CAUSE ANALYSIS: What happened?

DETAILS OF THE SENTINEL EVENTBrief descriptionWhen did the event occurWhat areas/services are impacted

DIFFICULTIES DESCRIBED IN THE CASEList facts or opinions described in the case that indicate a difference between WHAT IS and WHAT OUGHT TO BE

PROBLEM AREASGroup similar difficulties into problem areasWhat is the core issue in each problem area? (for example, how can hospital A achieve goal Y in light of constraints X, Y, and Z?)

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PROBLEM DEFINITION

ROOT CAUSE ANALYSIS: Why did it happen?

MOST PROXIMATE FACTORSFlow diagram of process in which event occurredWhere were the failures in the process

REASONS FOR FAILURESRoot causes by problem area“Initial Triage Questions” Root cause questions for typical problem areas

5th ORDER WHYFor every cause identified, keep asking whyEnsure you get to the root cause, not just the symptoms

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PROBLEM DEFINITION

RECOMMENDED SOLUTIONS

FIX THE ROOT CAUSESFor each set of problem areas

BARRIERS TO IMPLEMENTATIONAre solutions viable given organizational and environmental constraintsAre there stakeholders who will be opposed to the solutions and how will your change strategy address this?

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PROBLEM DEFINITION

IMPLEMENTATION

ROLES AND RESPONSIBILITIESHow will solutions be implemented?

TIME AND BUDGETAre time frames reasonable given immediate and long term needs?What resources are required to implement the solutions?

MONITORINGHow will you know if your solutions are having their intended effect?What will be monitored and how?

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PROBLEM DEFINITION

RESOURCE WEB SITES

ROOT CAUSE ANALYSIS RESOURCE

US Department of Veterans Affairs National Center for Patient Safety

http://www.patientsafety.gov/rca.html

Joint Commission Resources (2003). Root Cause Analysis in Health Care: Tools and Techniques, 2nd Edition.

http://www.jcrinc.com

PATIENT SAFETY RESOURCE

Institute for Healthcare Improvement http://www.ihi.org/ihi