How Does Senior Leadership Affect RCA in Healthcare?
I attended the Ohio Association of Healthcare Quality (OAHQ) Conference in Columbus last week and gave a talk on this subject. In any industry there is always some level of impact that senior leadership has on every process and system. From their expectations for the staff through their desire for the organization and business, these expectations become the guidelines within which we work.
When I talk to healthcare professionals I always hear the positive and the negative (usually in reverse order), and it is very rare that anyone is only on one side or the other. There is usually a mix. Some of the things I hear about are as follows:
- Unreasonable expectations for timelines in determining root causes
- Not providing a charter or guideline that provides the responsibilities of the team and communicates the abilities of the team/team leader
- Messages communicated from the Administration do not match with the “reality” of our working environment
- Corrective Actions that are recommended are not always implemented or followed and are substituted with managements own ideas that are not in alignment with the findings
- Our team feels like we are provided the necessary support to gather what we need to gather to understand the event
- Management supports our efforts to implement corrective and preventative measures following an adverse outcome
- The organization is very much a proactive group who truly want and desire to make our systems the best they can be
Now, looking at this list, we truly see how these issues are polar in ways. Different organizations have the opposite opinions from their counterparts. This is to be expected as each organization is different.
Looking at these comments and thinking towards TapRooT® and our Root Cause Tree®/Dictionary, where would these issues (if found to be causal factors) show up in the analysis? Well there is one primary area where I believe these truly match:
Management System – How Policies and the Actions of the Management System Impact the System
Of course this is not the only area that could show up as every investigation is different but these most certainly could have impact. And in addition to that, when investigating events you have to look at the outcomes (not root causes necessarily) from previous similar events. This portion of the analysis will gather data that could lead you to multiple root causes:
Management System->Corrective Actions->Corrective Action NI or Trending NI: If it is found that previous corrective actions were never implemented, or were not as effective as they could be you might be led to and those decisions were directly related to management decisions to change alter or not follow-up to see if the actions worked.
Management System->SPAC Not Used->Enforcement and/or Accountability: When examining events, if it is found that due to a lack of support from senior leadership to uphold investigative charters or uphold the level of responsibility given to the investigative team, then this could most certainly be a Management System issue.
These are just a few examples of how past performance can impact the events you investigate today. My recommendation is to always talk to people in your Management System to understand their expectation and compare that expectation to the actual messages received and heard throughout the organization. Then compare those messages to what happened during the event analysis to assess the actual impact. You might be surprised at what you uncover.
If you would like to know more about the TapRooT® process and our investigative philosophy please contact me directly at firstname.lastname@example.org or attend one of our training courses held worldwide www.taproot.com/courses and learn how TapRooT can help you improve performance. Thank you for reading!