Recommended plan for conducting an RCA investigation

Limit meetings and empower owners of the process to contribute to improvement strategies

This is the recommended framework for conducting a Root Cause Analysis (RCA) investigation. However, depending on the complexity of the case the process may vary on occasions.

NB: Investigation and Recommendations must be completed within 45 days of the incident
Before commencing a RCA investigation, the team must initially ascertain if the event is outside the scope of this review; that is, is it thought to be the result of:
  • a criminal act
  • a purposefully unsafe act
  • an act related to substance abuse by provider or staff
  • an event involving suspected patient abuse of any kind
If the event is thought to be related to any of the above, the event should not be investigated using this method but referred to the executive to be handled using the existing performance management structures in your organisation.

Meeting 1

Primary response: Secure evidence
  1. Make a simple flow diagram of the activities that surrounded and led to the event. Limit the diagram to five or six boxes and include only the key events that are crucial to understanding what happened. Eyewitness interviews lead you to the appropriate sets of questions. These will assist in identifying what you already know and what you need to find out.
  2. Having considered the initial checklist questions, and asking 'how, what and why' at each point of the flow diagram, an intermediate flow diagram can be developed.
  3. Any checklist questions you cannot answer can be used for interviewing others, gathering documents or obtaining applicable references, e.g. existing policies etc.
  4. Come back to the checklist questions often during the RCA.

Meeting 2: Part 1

Modelling Notations: flowcharting, time-person grid, reverse chronological timelines.
  1. Once all the information has been gathered, the team can construct the final flow diagram
  2. At each point in the flow diagram, the team should ask 'so what' or what is the relevance of each box in the incident chain.
  3. The team should identify whether barriers at each step might stop the problem from occurring again.
  4. The cause and effect diagram can then be constructed. This will assist in formulating the causal links leading to the contributing factors or root causes.

Meeting 2: Part 2

CAUSAL ANALYSIS
Primary response:
IDENTIFYING CAUSAL FACTORS
  • individual (patient), people (staff), task, team, work environment, organisational and management factors, inter-provider, external
  1. First, the team must outline what is the real problem to be eliminated, what happened that directly led to the event and what is the team trying to avoid.
  2. The team should brainstorm the most significant issues outlined in the final flow diagram and use these for the cause and effect diagram.
  3. Continue to ask 'why' at each box on the tree until there are no more answers. These are the contributing factors or root causes.

Meeting 3

Development of causation statements, actions and recommendations and key outcome measures — see actions and measures.

CLOSING THE LOOP
• Action Plan
Actions by whom, by when, resources required, completion, sign off
• Investigation Report
Lessons learned, residual risk
• Implementation
Communicate results, review practice, implement training, establish on-going monitoring, check other areas
• Evaluation
Have causes been addressed, recurrences eliminated or reduced, lessons learned and communicated, barriers to change unfrozen