finding the 'roots' of your problems and effective and imaginative ways of overcoming these

Root Cause Analysis ( RCA) - what is it ?
Who should do it?
When should you do it?
So how do you do a RCA?
Key things to remember with an investigation

Root Cause Analysis (RCA) - what is it?
Put quite simply Root Cause Analysis (RCA) is a way of conducting an investigation into an identified problem that allows the investigator(s), and other involved parties, to understand better the root, or fundamental, cause of the problem so that it can be put right.

Whilst many of you will believe that you are quite good at identifying solutions to problems it is not infrequently the case that the solutions you find do not actually address the issues that are at the heart of the problem.

Problems are a little like weeds, if you pull them out, invariably you resolve the issue for a while, but unless you've dug out the weeds by their roots they will in time return. The speed of return being fully dependant on the fertility of the soil it is bedded in.

Problems too, are like this. If you have not addressed, or removed, the real causes of the problem i.e. it's roots, and these are in 'fertile soil' i.e. they are provided with many avenues for developing and causing mischief, and you will be revisiting the problem you think you've solved much sooner than you think.

RCA therefore is about finding effective solutions to one or a multitude of problems as speedily as is humanly and mechanically possible.

Who should do it?
It is not recommended that a 'sole investigator' undertake a RCA investigation as the output is always more balanced and rich if an investigation team works together.

In healthcare RCA lends itself to full team participation, which can have a significant positive impact on the way a team, or teams, work together and engenders a real sense of being part of the solution rather than just part of the problem.

All RCA critical incident reviews should be facilitated by a trained member of staff, to ensure that all causal and influencing factors are identified and effective solutions considered.

Consequence can provide your staff with this training: enquiries@consequence.org.uk

When should you do it?
RCA principles to be applied to all problem solving activities. However a full RCA would normally be applied to high risk or high impact events.

For those incidents, and near miss events, where this is not immediately obvious a simple Risk Assessment Tool can assist you in identifying these events with a greater degree of consistency and consensus than might otherwise be possible.

So how do you do a RCA?
Whilst RCA is essentially a simple process some training in the theory underpinning its application, and opportunity for facilitated competency development is advised.

In its raw essence RCA is dependant on the enquiring and broad-thinking mind. However there are a number of processes, especially when applying RCA to the investigation of adverse events, which must be followed if RCA is to be effective.

Fundamental to good RCA is the application of good investigative techniques, and good 'drilling' techniques. These do not have to be clever and complex, indeed simplicity has significant appeal in this field, especially if you are trying to inculcate RCA philosophy into every day practice.

In the context of the increasingly busy working lives of clinicians, support services and health service managers, a range of RCA tools that are easy to use, easy to implement, require the minimum of time, and deliver relevant results, as well as engaging the attention of, and inspiring enthusiasm amongst participants is what's required.

The range of training programmes provided by Consequence aim to provide all participants with such a range of tools that can be used for effectively getting to the nub of a problem, or issue, regardless of the route of identification - e.g. adverse event, proactive risk profiling, team meeting etc.

Maria Dineen, principal director of Consequence has recently produced an easy to follow manual on RCA in Healthcare Organisations called Six Steps to Root Cause Analysis. To view a preview click here, or to download an order form click here.

Human Factors Taxonomies
Identifying the influencing factors to identified problems is a vital part of the RCA process. To undertake this task the 'human factor taxonomies' provide a framework within which to operate. The taxonomies also make one consider a comprehensive range of avenues within which an 'influence' to the event, or problem may be embedded.

In healthcare the work undertaken by Dr Sally Adams, (Research Fellow at the Clinical Risk Unit, University College of London, and Independent Human Factors and Safety Consultant), in defining Human Factor Taxonomies, that might be most applicable to the healthcare environment, has set the framework that many health practioners use for this.

The headings for this framework are:

• Patient
• Individual Practioner/Staff member
• Workforce and Team issues
• Environmental and equipment issues
• Task and process
• Organisational issues
• External stakeholder / legislative issues

**The ALARM/CRU Investigation Protocol for investigating Serious Clinical Incidents contains an informative chapter on the identification of influencing factors associated with adverse clinical events. This can be found at: www.patientsafety.ucl.ac.uk

There are other approaches to identifying core 'taxonomies' and interested readers are encouraged to access the Joint Commission for the Accreditation of Healthcare organisations publication 'Root Cause Analysis in Healthcare - Tools and Techniques' by telephoning JACHO in the USA via 0-86688-641-9 (document code RCA-100) and the Veterans Affairs National Centre for Patient Safety at www.patientsafety.gov

The use of Fishbone diagramming also works well with the human factor taxonomies.

Key things to remember with incident investigation and RCA:

• Don't fall into the trap of thinking the problem and therefore the solution is obvious
• Make sure you are aware of the causal relationships
• Don't jump in with solutions
• Ensure, improvements that you can implement are owned and signed up to by your team (or the team they affect)
• Ensure that you only take responsibility for actions you have control over; you cannot agree an action plan for something you can't implement
• Make sure that anything you do meets your goals and objectives i.e. that it provides cost benefit and doesn't create a bigger problem elsewhere
• Finally try not to be paralysed by the scarce resource available to resolve quality. Whilst there are issues that require significant resource and the support of the corporate organisation, if not a national response, there are many risk and safety issues that can effectively be reduced within existing resource. We don't just have to live with them.

E.g. There is little any of us can do about the type-size on drug ampoules - this requires a national response by such agencies as the National Patient Safety Agency and the Purchasing agencies, however a magnifying glass in each treatment room might go a long way to resolving some of the difficulties posed by small lettering in the immediate short term.

E.g. We know that double drug checks are reasonably ineffective, where two persons undertake the check together, so why don't we take a leaf out of industries book and institute a double checking system where the 'check' is undertaken by two individuals separately.

E.g. Many equipment check forms do not prompt action by the checker if there is anything untoward. A simple form redesign can make the process much more directive, remind the individual of their accountabilities, and prompt appropriate action and referral.