Root Cause Analysis (RCA) “is a structured method used to analyze serious adverse events” in healthcare (1). The RCA process seeks to improve patient care by identifying breakdowns in the systems that increase the likelihood of a harmful event or incident. (1)
As healthcare organizations understand and identify common events and trends, they are restructuring their RCA processes to reflect those insights. Leadership teams are now shifting away from identifying the ‘what’ and ‘who’ of the RCA process in favor of identifying the ‘why’. This human-centered approach considers common patterns of human behavior when analyzing systems to identify problems and generate solutions. (2) There is an emphasis on trust and positive change, rather than blame. (3)
Identifying human factors in process design was a concept originally used in the field of engineering. The term 'user-centered design' was coined by Donald Norman in the late 1980s. (2) This technique prioritizes the “relevant characteristics of a user throughout the design of a product or system” (2), entailing a search for system vulnerabilities rather than individual human errors and other less actionable root causes. (4)
It is neither feasible nor desirable to complete an RCA following every incident report. For example, one 600-bed private hospital generates 15,000 incidents reports annually—an impossible number to investigate with RCA given that the process takes more than 20 person-hours and over $8000 to complete. (5)
To improve efficiency, leadership teams in healthcare are now focusing on designing human-centered approaches to root cause analysis:
1. Build Effective Communication and Promote a Culture of Safety
Communication is the cornerstone around which a team is built; it should be done with trust, understanding and without fear of hierarchy. (2) To support effective communication, leadership teams are beginning to shift from a punitive culture to a more supportive environment that emphasizes trust and a positive “safety culture” throughout the RCA process. (6)
Safety cultures facilitate detection and sharing of errors, reflection upon and understanding of underlying causes, and increased dedication to improving safety. (7) Establishing a safety culture is crucial in the RCA process because after an RCA is performed, it is common for organizations to experience communication gaps. Organizations should cultivate a safety culture by pausing and sharing the findings of the RCA with caregivers outside of quality and risk management, so that the whole team can learn from mistakes.
Another element of promoting a culture of safety is to perform daily safety huddles.
Daily safety huddles are brief, routine meetings for interdisciplinary team members to share information about potential or existing safety problems facing patients or workers. (8)
Safety huddles help promote a culture of discussion and learning after the RCA process, and can lead to the prevention of adverse events in the future.
2. Identify the Human Aspect of Incidents
Human-centered design is an approach to problem-solving that puts employees first.
Humans have limitations and make errors from lack of knowledge or experience with a process, misinterpretation, or simply attention and memory breakdowns. Human failures cause 80% to 90% of errors. (9)
Instead of targeting which employee was involved in the error, a human-center design addresses the process breakdown, workforce challenges, and perspectives. When applied to the RCA process, human-centered design goes beyond asking “which employee was involved?”, and attempts to gain deeper levels of understanding by addressing “why did it happen?” and “how could it be prevented?”.
For example, if a patient broke their hip during a hospital stay, the human-centered approach towards RCA would ask questions such as:
- Why did the patient break his hip? Answer: Because he fell.
- Why did the patient fall? Answer: Because he lost his balance.
- Why did he lose his balance? Answer: Because he had nothing to hold onto.
- Why was there nothing for him to hold onto? Answer: He was unable to use his walker.
- Why was he unable to use his walker? Answer: The walker was in the closet and not readily accessible for his use.
- How can this be prevented in the future? Answer: Move the walker from the closet to the patient’s bedside.
3. Address Bias
Many biases can exist in the RCA process; however, these can be addressed through education and training. (2) Reducing biases by understanding human thought processes, emotions, and behaviors helps guide the user-centered design of the RCA.
For example, an RCA can address biases such as (10):
- Fundamental Attribution Error: a bias that includes using natural tendency to describe someone else’s behaviors.
- Us Against Them Bias: investigators carrying out bias against people doing different jobs than themselves.
- Severity Effect: the bias that leads us to believe that large outcomes have large causes.
- Temporal and Spatial Contiguity: Allowing factors to be causal just because they happened close to or at the same time as the outcomes.
It’s important to choose the right people to be part of the RCA process who can remove the potential for bias. Team members should be selected for their ability to discuss and review what happened during the event in an objective and unbiased manner.
In some situations, staff members not personally involved in the event are the best people to serve as reviewers, and the people personally involved can be asked to share their experience during interviews. This may be appropriate if the people directly involved in the event are dealing with emotions and are not able to be objective. (10)
4. Implement an Electronic RCA Process
One way to achieve higher quality outcomes is to implement a an incident reporting software that includes RCA as part of the follow-up management process. Instead of tracking reports on paper or in Excel, an incident reporting software can help organizations track all of that data in one place. Then, it is much more efficient to conduct an accurate root cause analysis.
By encouraging the sharing of information, putting processes in place for effective communication, and promoting a culture of safety, conducting effective root cause analysis through an electronic solution can positively impact quality outcomes.
Performance Health Partner’s Solutions
Performance Health Partner’s Incident Reporting Software allows for interdisciplinary teams to easily collaborate on systemic issues that lead to adverse events, allowing organizations to take a collaborative approach that is focused on learning and lasting improvements. Learn more at performancehealthus.com/patient-safety or schedule a demo here.
1. Root Cause Analysis. Patient Safety Network. Agency for Healthcare Research and Quality. Retrieved on August 7, 2019 at https://psnet.ahrq.gov/primers/primer/10/root-cause-analysis
2. Searl, M.M., Borgi, L. & Chemali, Z. It is time to talk about people: a human-centered healthcare system. Health Res Policy Sys8, 35 (2010). https://doi.org/10.1186/1478-4505-8-35 Retrieved from https://health-policy-systems.biomedcentral.com/articles/10.1186/1478-4505-8-35)
3. Diller, T., Helmrich, G., Dunning, S., & Shappell, S. A. (2012, December 11). A Human Factors Approach to Root Cause Analysis [Symposium presentation]. http://app.ihi.org/facultydocuments/events/event-2206/presentation-7683/document-5752/a6_b6__presentation.pdf
4. Oppenheimer DM: Spontaneous discounting of availability in frequency judgment tasks. Psychol Sci. 2004, 15: 100-105. 10.1111/j.0963-7214.2004.01502005.x. Google Scholar
5. Hagley, G., Mills, P. D., Watts, B. V., & Wu, A. W. (2019). Review of alternatives to root cause analysis: developing a robust system for incident report analysis. BMJ open quality, 8(3), e000646. https://doi.org/10.1136/bmjoq-2019-000646
6. The Patient Safety Systems (PS) chapter of The Joint Commission Accreditation Manual. Retrieved from https://www.jointcommission.org/patient_safety_systems_chapter_for_the_hospital_program/
8. Hoff T, Pohl H, Bartfield J: Implementing Safety Cultures in Medicine: What We Learn by Watching Physicians. Advances in Patient Safety. 2003, 1: 15-38. Google Scholar