Expanding the Scope of RCA in Healthcare
For many years, the culture within healthcare has been focused on reducing medical errors, minimizing impact on the patient through sentinel event analyses, performing proactive analyses on high risk processes using FMEA and raising awareness about risk reduction and patient safety.
All of these efforts have huge merit and a very high visibility within and outside of the healthcare community. When we enter a hospital we (as clients and patients) have the expectation to leave in better shape than we arrive. We certainly do not expect harm to come to ourselves or our loved ones but when things can and do happen the expectation is that the organizations will learn and improve. Thus resources and money are applied to the RCA programs around these visible events.
So with all these programs and efforts put towards the “clients” within healthcare I have always wondered, “Are there resources or efforts left for workplace safety within healthcare?”.
The article on “10 top safety issues for 2016” by Becker’s Infection Control and Clinical Quality Newsletter brought this thought back to me by listing the following 2 items as risks towards Patient Safety:
1) Workplace Safety, focused on the safety of healthcare workers
2) Hospital Facility Safety, focused on building or maintenance type issues
When I read the entire list it was so in line with our philosophy on the impact of systems and the workplace on healthcare professionals themselves. When we think of performing root cause analysis we think of problem solving, fixing what was wrong by implementing corrective/preventative measures and thereby creating a safer environment. If we create a safer environment for those who work in a healthcare setting, our caregivers, wouldn’t we also be creating a safer environment for patients and visitors within the same framework? I believe so.
One of the first principles we teach in all of our TapRooT® training programs involves defining the “incident” or in healthcare terms the “Event.” This becomes the circle on our SnapCharT® and by its nature is the focus of the investigation and the issue or occurrence we want to prevent in the future. The incident can be ANY problem you wish to solve, ANY adverse event or occurrence needing evaluation… it does not have to solely sit at the top of the Patient Safety or Risk hierarchy.
Let’s take a quick quiz, here is the question:
Which of these issues could be investigated using the TapRooT® Methodology?
A) Medication error resulting in long-term harm to a patient
B) Nurse strains their back trying to reposition a patient causing lost time
C) Patient spouse slips on a loose tile in the main hallway outside the Pharmacy
D) Hospital administrator slips on water leaking from the fire system in admin wing
E) Backup generator does not start in time to provide uninterrupted power
F) All of the above
Well what do you think?
If you answered “F – All of the above” you are correct! All of these problems or issues can cause adverse impact to your organization. All of these problems can cause a cascading effect on both patient care as well as employee safety.
The TapRooT® process has tools and a language that fits all these situations without having to change your RCA approach or methodology. The same thought process applies to both the clinical and non-clinical issues facing your organization. The 7-step Process Flow used in the Sentinel Event training course is the same that we use in our Equifactor® (Equipment Troubleshooting) training course, as well as our public RCA seminars. Human Performance and Equipment performance are the same from the investigative perspective no matter what the problem you are trying to solve.
So as we enter 2016, I want you think about others inside your organizations outside of the clinical organizations that can benefit from the same tools Patient Safety and Risk Management use in TapRooT®. Maximize your use of the process to maximize your return on investment in training… your facility maintenance personnel, your facility administration personnel… anyone who is tasked with problem solving and troubleshooting can benefit as well. Create a safe work environment for those closest to you (your employees), and you also create a safer environment for your clients (patients and our loved ones).
If you would like information on our training courses for Root Cause Analysis, Equipment Troubleshooting, Evidence Collection or any other TapRooT® courses please contact me at firstname.lastname@example.org or call me at (865) 539-2139. I would love to help you create the total environment for patient care.