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  • Root cause analysis: Why we need to change the focus

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    Summary

    This short blog from Jerome, a patient safety manager, gives a brief description of root cause analysis and asks why the NHS spends so much time generating root cause analysis reports rather than focussing on what changes should happen afterwards to current systems and processes.

    Content

    What is root cause analysis?

    Root cause analysis (RCA) is a structured method used to analyse serious adverse events. Initially developed to analyse industrial accidents, RCA is now widely deployed as an error analysis tool in healthcare.

    The RCA approach is the current methodology to investigate why and how serious incidents have happened in healthcare and to assure the Trust, Clinical Commissioning Group (CCG) and the patient/family that lessons have been learned and that the incident will not happen again.  This methodology is soon to change next year as set out in the new Patient Safety Incident Response Framework.

    What happens to the report?

    Once written, the RCA report will be sent to the CCG, other outside bodies and the patient/family, alongside an action plan on how practices will change. 

    What type of incident is RCA used for?

    Many Trusts will perform an RCA on incidents which are deemed to have greater learning for the Trust despite the degree of harm, moderate harm and above, and never events.  Most Trusts use a modified RCA for ‘local’ investigations – these incidents may include pressure damage, falls and medication errors.

    What is the process?

    The current process of undertaking and processing a serious incident is laid out below.  This is taken from the NHS Serious Incident Framework.  Many Trusts will provide RCA training to anyone undertaking the lead role in an investigation – this could be a patient safety lead or a clinician.

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    How long does it take to complete an RCA?

    This can depend on the experience of the investigator, the capacity of the department involved to collect statements, a timeline and information.  If the incident has been declared to the CCG, the report will need to be completed within 60 days. A local RCA should take no longer than 4 weeks.

    How many RCAs are completed each year in the UK?

    During 2018 there were nearly 62,500 incidents that were reported as moderate harm or above. The majority of these would require an RCA. This figure does not include incidents that were not reported on to the Strategic Executive Information System (StEIS) but were investigated using the root cause analysis locally. 

    Currently, patient safety teams up and down the country are drowning in writing RCA reports.

    We are caught up in a process of investigating harm that has already happened. Hours, days, months are spent having meetings mulling over the RCA. Looking at timelines, thinking of why the incident happened and whether there was any way for it to have been prevented.

    The cost of undertaking an RCA must be in the thousands of pounds. The team often includes the patient’s consultant, head of nursing, governance leads, patient safety managers and clinical staff.  This group may meet up at several different occasions to make sure that all facts are correct and that the RCA is written well and meet a standard that the CCG will accept.  Multiple drafts are written before submitting the final report.

    Action plans are found at the bottom of the RCA – once the root causes have been found, that is when the actions can be formulated. These actions will need to be carried out in the department/area where the incident took place or across the Trust if it was a system failure.

    Once written and signed off by the Trust and the CCG – the RCA is complete.

    What happens next?

    The end of the RCA should be the beginning of either a quality improvement initiative, a new policy, a change in practice or change in process. This part of the process is often poor – ‘reminding staff’, ‘education’ and ‘reflection’, assuming it must be human error and must be ‘fixed’ by telling people how to do it better. There is little training in setting appropriate actions or a centralised place to evidence that the action is now imbedded. 

    The Care Quality Commission (CQC) can call on these actions and the evidence of these actions at any time.

    At present there is not a robust, standardised approach across the NHS to gather evidence that actions have been put in place post incident.

    One of the reasons for this is a lack of capacity and capability due to the industry we have made of writing the RCA and lack of quality improvement training or time provided to all staff throughout the NHS.

     Final words

    Have we forgotten the purpose of our role within patient safety?

    Figuring out what went wrong systemically is only one part of our role; however, assuring the family and patient that we have put new systems in place and that we are striving for this incident to never happen again is equally, if not more, important – so why is there not a standard process/industry for this? If we focussed more on the prevention we could get off the hamster wheel of investigating recurrent harm.

    It is hoped that the new serious incident framework will address this issue and allow us the time and the capability to put in measures to stop recurrent harm happening to patients and the public. 

     What are your solutions to action plans and gathering the evidence for these plans?

    Have you a system that is easy to keep track of RCA reports and follow up?

    I would also be interested in the patient/public view of investigation reports and whether this type of approach is what they want? 

     

    About the Author

    Jerome is a patient safety manager in an acute NHS Trust in the North of England.

    5 reactions so far

    10 Comments

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    Very well made points. I think the new SI framework is indeed intended to address the 'hamster wheel' approach. It would be good to hear from the pilot sites how they've approached the challenges you outline and the approach to taking appropriate action - evaluating and sharing the impact of quality improvements. Would be great to get these on the hub.

    Will be of interest to you, I'm sure  @Jon Holt

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    I think the point is if you have a good investigation, the learning will identify itself.

    However, most trusts are not interested once the RCA has been signed off.

    The action plan is sometimes forgotten or fudged to show it is completed.

    Worst it's changed by the clinical director to fit their needs.

    I hope this new scheme readjusts the balance.

    From what I have read, trusts will now have to be really honest and accountable and sorry but I cannot see this happening.

    I can see trusts saying lets just do an audit, it's so rare this happens etc., I am worried where we are going.

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    I completely agree with you @Katrina.  More often than not, post RCA, there are numerous actions but little assurance that they are being completed in a timely manner.

    Readdressing the balance is so important.  The Patient safety managers voices are so very small - we all know its not right...so why are we not kicking up a fuss?

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    @Jerome P in my experience most trusts do have mechanisms in place for tracking actions and do endeavour to see things through but things can also fall by the wayside where there are other competing pressures and priorities and the immediate time pressure to complete the RCA has subsided.

    However, I think the bigger problem is that the recommendations and actions generated from the RCA are often not addressing genuine root causes and are not system focused. They can be supeficial or ineffective actions focused on individuals and developing and revising policies etc. This is because investigations often stop at the point of identifying what went wrong and how rather than focusing on the working conditions, environment, team dynamics, culture and other human factors / systems factors which need to be explored to identify why things went wrong and generate meaningful solutions. 

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    @Jon Holt Spot on ‘This is because investigations often stop at the point of identifying what went wrong and how rather than focusing on the working conditions, environment, team dynamics, culture and other human factors / systems factors which need to be explored to identify why things went wrong and generate meaningful solutions. 

    How can we make the changes needed @Katrina and @Jerome P?

    @Claire Cox suggested on Twitter this weekend a network of PS Managers. That would help amplify the voices for change and to share good practice and ideas.  

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    Hi @Jon Holt Ive been saying that actions don't reflect the true root causes for a while.  This is an elephant in the room.  Im hoping the new framework will help.  But the old world usually bites back, and usually twice as hard.

    What is the solution?

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    A PS Manager from a Trust told me recently that the investigations they did there were largely driven by the contract with their CCG. They HAD to investigate every serious pressure ulcer. The recommendations were generally the same, and nothing ever changed. Perhaps @Jon Holt the CCGs might change so that there is less emphasis on repeating investigations into an issue ad infinitum, and more emphasis on actual implementation of recommendations and evaluating the impact of them.

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    @Clive Flashman this doesn't surprise me. ultimately, it is down to providers and commissioners what contractual requirements they locally identify. I think in this instance the provider really needs to be more assertive when it comes to negotiating this to identify that this is something which isn't helpful. Equally some of the behaviours of CCG's when it comes to what they measure and the requirements they place on providers can be unhelpful and counterproductive even if well intentioned. 

    This is where the new framework is intended to help - the idea is that where the underlying causes of an issue are the same there should not be a requirement to investigate each incident individually with more of a focus being placed instead on implementation of quality improvement plans. I can certainly see the benefit of an approach where not every single category 3 or 4 pressure ulcer is investigated via an in-depth RCA but alternative forms of review are used instead and the focus is on addressing underlying common themes. The devil will be in the detail though when it comes to implementation though but the apsiration is the right one in my view 

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    @Jerome P I think the national strategy and new framework can help here - they certainly have the right ambitions. Trusts need to build more expertise and knowledge in human factors, systems thinking, quality improvement, safety science etc which can be applied to lead to more effective investigations which identify the genuine root causes and appropriate solutions. Ultimately though to achieve the kind of change required it will require sustained support and focus including from national and regional teams to continue to drive this agenda

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    @HelenH the network of patient safety managers is essentially already happening via the creation of patient safety specialists, they will be the key group to take initiatives from the national strategy forward. so it's essential they have the right training, support, networks and opportunities to take things forward. time will tell but think it is a positive step

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