March 4, 2020 | Mark Paradies

Research on Root Cause Analysis Effectiveness in a Healthcare Setting

Root Cause Analysis – Does Research Show It Is Effective?

There have been several studies on the effectiveness of research on stopping healthcare sentinel events and other quality issues in healthcare settings. Today, I will refer to a review, Our First Review in 12 Years: An Evaluation of Effectiveness of Root Cause Analysis in Hong Kong Public Hospitals, published in BMC Health Services Research. The study looked at 214 root cause analyses performed in Hong Kong hospitals.

Summary of RCA Research Results

Here is a summary of what the published results were:

A total of 214 reports from October 2016 to September 2018 were reviewed. These reports generated 504 root causes, averaging 2.4 per RCA report, and comprising 282 (49%) system, 233 (46%) staff behavioural and 22 (4%) patient factors. There were 658 recommendations identified in the RCA reports with an average of 3.1 per RCA. Of these, 18 (2%) recommendations were rated strong, 116 (15%) medium and 626 (82%) weak. Most recommendations were related to ‘training and education’ (466, 61%), ‘additional study/review’ (104, 14%) and ‘review/enhancement of policy/guideline’ (39, 5%).

Have you heard about results like that before? We see that as typical root cause analysis and typical corrective actions BEFORE implementation of advanced TapRooT® Root Cause Analysis.

What’s Wrong with Healthcare Root Cause Analysis?

The review team had fairly good conclusions when analyzing the failures of the current root cause analysis efforts at Hong Kong hospitals. They said:

The results showed a high proportion of root causes were attributed to staff behavioural factors and most of the recommendations were weak. The reasons include the lack of training, tools and expertise, appropriateness of panel composition, and complicated processes in carrying out large scale improvements.

Does this result sound typical to the results at healthcare settings around the world? I would say YES! I would even suggest that these types of results occur wherever “simple” root cause analysis is applied.

Where the research team went astray was in their recommended fixes. They said:

The Review Team suggested conducting regular RCA training, adopting easy-to-use tools, enhancing panel composition with human factors expertise, promoting an organization-wide safety culture to staff and aggregating analysis of incidents as possible improvement actions.

Why is this bad advice?

  1. Training in “simple tools” (like 5-Whys) won’t get you where they want to go. Simple tools are part of the problem.
  2. They won’t have enough human factors personnel to help with the investigations and even these people need a systematic tool to help assure good investigations.
  3. Aggregation of bad analysis doesn’t provide worthwhile statistics.

So, what should they recommend?

  1. Implement advanced root cause analysis based on the fundamentals of good root cause analysis. Where can you learn about the fundamentals of good root cause analysis? Try THIS LINK.
  2. Make sure the system you implement GUIDES people to the root causes of human performance problems.
  3. Choose a system that has been successfully implemented around the world in a variety of industries.
  4. Choose a system that guides investigators to strong corrective action.
  5. Choose a system that IS NOT blame-oriented and guides investigators to FIRST look for what happened BEFORE starting to analyze WHY the accident happened (the root causes).
  6. Make sure the system helps you identify all the Causal Factors and all the root causes.

What system meets the criteria listed above? The TapRooT® Root Cause Analysis System.

Not only does the system meet those criteria, but the TapRooT® Training is also GUARANTEED:

Attend this course, go back to work, and use what you have learned to analyze accidents, incidents, near-misses, equipment failures, operating issues, or quality problems. If you don’t find root causes that you previously would have overlooked and if you and your management don’t agree that the corrective actions that you recommend are much more effective, just return your course materials/software and we will refund the entire course fee.

That shows how confident we are that you won’t be wasting your time when you attend TapRooT® Training to stop your patient safety-related issues.

Where can you find out more about our TapRooT® Courses? Try this LINK.

Check out THIS LINK for the location of our public TapTooT® Root Cause Analysis Courses being held around the world.

We hope to see you and your root cause analysis team at a course soon to help you stop these serious patient safety incidents.

Categories
Patient Safety & Healthcare, Root Cause Analysis
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