Root Cause Analysis: A Six-Step Process For Problem-Solving

What is Root Cause Analysis?

Purpose of conducting root cause analysis (RCA)

Root cause analysis is a problem-solving method that is used for identifying the root cause of a problem. A factor is considered a root cause if removal of the factor will prevent undesirable outcome from recurring. Root cause analysis is conducted with the objective of identifying the leading cause of a problem rather than merely addressing the symptoms of the problem (Leonard, Joint Commission Resources & Institute for Healthcare Improvement, 2013). After identifying the root cause, it is possible to find a solution to the problem and hence ensure the problem does not occur again.

Six steps of the RCA process

The following are the six steps followed when performing RCA as defined by IHI;

The first step of conducting RCA is fact gathering using a timeline and interviews. This step requires the facilitator/investigator to review documents that are related to the event. Such records may include medical reports and incident reports. For our case study with nurse J who was taking care of patient B, an interview will be arranged with both the nurse and the family of the diseased to help investigate the events that led to the undesired situation (Myers, 2012). Medical records from the hospital and the facility in which the patient was transferred will also be investigated to provide information on what could have happened. The standard policy of the hospital was that a patient who is sedated should remain on continuous B/P, ECG and pulse oximeter until the patient meets the specific discharge criteria. The team needs to investigate why standard procedure and policy was not followed on this patient.

The second step understands what happens. In this step, the facilitator or the person investigating the incident should review established timelines with everyone in the team (Hay, Levin, Deterding & Abzug, 2014). The team should then compare the schedule of events with the actual sequence of events that should be followed according to the policy or best practice guidelines. Patient B was left on automatic blood pressure machine with his son. Standard procedure and systems of the hospital require that such a patient should never be left alone and they should always be under the care of a registered nurse. Nurse J was also allocated so many patients on that night despite there being backup staff in the hospital. The nurse was well trained in sedation training module and was well qualified. The nurse also did not have a history of negligent patient care.

The Six Steps of the RCA Process

The third step is the determination of the root causes. The team, based on the analysis carried out in the previous step brainstorms the root cause of the problem by asking questions such as Why? How? The causal factors are categorised, and then the contributing factors which would not prevent recurrence but are significant are isolated and listed. One of the possible causes of the unfortunate event is that nurse J failed to follow the policies and procedures laid down by the hospital management.

Step four is developing casual statements. A casual statement links the identified causes to the effect of the problem and then to the event that prompted RCA. The casual statements explain how contributory factors contribute to undesirable outcomes (Marshall, 2010). The problem might have occurred because poor communication between doctor T and nurse J. The other nurses who were supposed to be on duty that night may have failed to report to work and hence overwhelming nurse J with a lot of work. The negligence of the nurse might have contributed to the death of patient B.

The fifth step is generating recommended actions which will help in solving the problem. Some recommended actions are more effective than others. The National Center for Patient Safety classifies the actions into robust, intermediate and weak actions. Nurse J can be offered additional training to prevent recurrence of the event. More nurses should be on duty to help handle emergencies.

Step six of the process involves writing up a summary and sharing it with the relevant audience. This is an excellent opportunity to clarify information about the event and present the recommendation so that they can be implemented.

1. Process improvement plan

To come up with a process improvement plan, an audit should be conducted to identify the exact areas that need improvement. An independent review should be undertaken to determine the number of nurses on duty at each given time. This is then compared to the required standards regarding staffing. Customers will also be interviewed to determine their level of satisfaction and take appropriate action.

Step 1: Increase the number of nurses for each shift

Step 2: Increase the number of doctors working in the emergency department.

Step 3: Offer staff additional training to help them understand how to deal with pressure at the workplace.

Step 4: Improve communication among the medical staff

1) Lewin change process

Unfreeze-The management of the hospital should make a random change in staffing at the hospital and redesign how activities are run at the facility. The hospital should increase staff in each department and change the work routines to ensure nurses are available in case there are many patients who need emergency care.

Step 1: Fact Gathering

Change- Build stability after staff at the hospital has opened up their mind on the change. During this stage, both nurses and doctors will have started getting adapting to new roles and tasks (Joint Commission Resources, Inc, 2017). The hospital management should carry out monitoring to ensure the new changes in scheduling and training adheres consistently.

Freeze- This will involve making the change stick and become a routine at the workplace. Staff will get used to the changes and implementation will be easier and hence ensure undesired circumstances do not occur again in future.

C)  The purpose of failure mode and effect analysis is to study the reliability of systems in an organization and identify how and why the systems might fail.

1)FMEA involves the following steps:

Step 1: Select a process to evaluate with FMEA. This involves selecting a specific process that should be evaluated (Malloch, 2017). The process should be simple and should not have so many sub-processes.

Step2; Recruit a multidisciplinary team. All the people involved in the event should be included in this team. This will help in collecting all the vital information that is critical for analysis. Nurses, Doctors at the ED, receptionist and the hospital management should be involved in this process.

Step 3: Have the team meet together to list all of the steps in the process. Every step in the process should be numbered and a flowchart designed to help in outlining each step.

Step Four; Listing failure modes and causes. In this step, the team lists all things that went wrong and then identifying what could have caused each of the problems.

Step Five: For each failure mode, assign a risk priority factor(RPN). The likelihood of each event occurring is assessed, and so that focus can be put on more risk factors (Rohde & HCPro,2014).

Steps in the Improvement Plan Process*	Failure Mode	Likelihood of Occurrence (1–10)	Likelihood of Detection (1–10)	Severity (1–10)	Risk Priority Number (RPN)
EXAMPLE: Doctor orders medication for pain prior to invasive procedure.	Wrong medication selected	3	5	5	75
1.Increase number of nurses per shift	The nurse and the doctor at the ED were overworked hence resulting to fatigue	3	5	4	60
2.Increase number of nurses in ED.	Insufficient financial resources	7	5	7	80
3. Offer staff additional training	Neglect of patient and breakdown in communication	3	4	3	55
4.Improve communication among the staff	Failure to communicate effectively and poor procedures and processes	4	3	4	65

1. D) I would test the intervention of increasing the number of staff working per shift in the hospital by carrying out a weakly and monthly audit on the number of nurses on duty at each particular time. The efficiency of services at the hospital will be evaluated by determining the number of doctors in the emergency department (Crowell, 2016). Weakly surveys will be conducted in each department at the hospital with the objective of obtaining feedback on the quality of services they received from the medical staff in the hospital. The results of the audit would guide us in determining the actions to be taken to avoid the occurrence of a similar situation.

Step 2: Understanding What Happened

E) A professional nurse can demonstrate leadership in promoting quality care by involving patients and their families in making decisions about their health (Vanden & ABS Consulting, 2008) This is important since it offers patients a chance to choose on what is right for them and hence ensure that they get the best quality health care. Another way in which a nurse can demonstrate leadership is undertaking continuous monitoring and assessment of the patient to address complications and reduce risks. Nurses also educate family members and patients for discharge to reduce the risk of the patient getting ill again.

The nurse can demonstrate leadership in improving patient outcomes by promoting well-informed diagnosis to ensure high-quality treatment. Nurses should also support optimal treatment planning. Transparency will also improve patient outcomes at the hospital. A nurse can demonstrate leadership in improving patient outcomes by showing concern and respect for patients as well as fellow workers. This helps in creating trust and hence bringing about motivation. A nurse can also demonstrate leadership by being task oriented and providing direction and clarification of tasks.

Leadership in quality improvement process can be demonstrated by nursing engaging in training and development activities. This will help in increasing knowledge and equipping nurses with skills required to handle complex medical situations. Processes can be improved at the hospital by increasing the number of staff working during each shift. Nurses should engage in research consistently to identify any necessary change and identify models for improvement. Designing an evaluation plan will also be important in the quality improvement process.

Reference:

Crowell, D. M. (2016). Complexity leadership: Nursing’s role in health care delivery.

Hay, W. W., Levin, M. J., Deterding, R. R., & Abzug, M. J. (2014). Current diagnosis & treatment. New York: McGraw-Hill Medical.

Joint Commission Resources, Inc., (2017). Root cause analysis in health care: Tools and techniques.

Leonard, M., Joint Commission Resources, Inc., & Institute for Healthcare Improvement. (2013). The essential guide for patient safety officers. Oakbrook Terrace, IL: Joint Commission Resources.

Malloch, K. (2017). Quantum leadership: creating sustainable value in health care.

Marshall, E. S. (2010). Transformational leadership in nursing: From expert clinician to influential leader. New York, NY: Springer.

Myers, S. (2012). Patient safety and hospital accreditation: A model for ensuring success. New York: Springer Pub. Co.

Rohde, K. R., & HCPro (Firm),. (2014). Beyond root cause analysis: Building an effective program.

Timmins, N. (2015). The practice of system leadership: Being comfortable with chaos.

Vanden, H. L. N., & ABS Consulting. (2008). Root cause analysis handbook: A guide to efficient and effective incident investigation. Brookfield, Conn: Rothstein Associates Inc.