Going Beyond Root Cause Analysis

Root Cause Analysis (RCA) has long been used in health care after adverse events occur to answer the question, “How did this happen?” A panel of experts convened for the 2015 Improving Root Cause Analyses and Actions to Prevent Harm report determined that preventing future harm requires action. Consequently, they renamed the process Root Cause Analyses and Actions or RCA² (RCA “squared”) to emphasize the importance of eliminating and mitigating system vulnerabilities. In this post, IHI answers some common questions about RCA².

Who should be on an RCA² team?

The RCA² team members are assigned by the organization’s leadership to officially serve on the team. These are the individuals who attend all the meetings, conduct the research, interview staff, identify root cause contributing factors, and write the report. In most cases, this team also identifies the corrective actions and their associated process/outcome measures, though in some organizations an individual or another team may complete this task.

Why is it best to exclude staff involved in the adverse event from the RCA² team?

When we use the term “member of the RCA² team” we are specifically referring to those individuals who have the ultimate decision-making authority regarding the final output of the RCA². Some people refer to these individuals as the voting members of the team. To understand what happened and why it happened, it is necessary to talk openly during the team meetings about the actions of those individuals immediately involved in the event. If those involved are part of this discussion, other team members may refrain from speaking up or may self-censor what they say to spare these individuals from further mental anguish or to avoid hurting their feelings. 

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Also, those involved in the event may be overly harsh when judging their own actions and advocate for corrective actions that others do not think are necessary. Less likely is the possibility that those involved may steer the team from for looking deeply into an area that they feel will not reflect well on them individually. These disadvantages outweigh the benefit of having the involved staff on team. 

The involved staff can and should be interviewed, as it is helpful to understand what actions they think should be implemented to prevent a recurrence of the event, but they should not be the ultimate decision makers of the official output of the RCA² team. This also minimizes possible criticisms that the output of the team was unduly influenced by an inherent conflict of interest. The involved staff also must be given feedback about the final action items that result from the process.

Why is it best not to have patients involved in the event or their family on the RCA² team?

As in the answer above, when we use the term “member of the RCA² team,” we are specifically referring to those individuals who have the ultimate decision-making authority regarding the final output of the RCA². It is appropriate to interview the involved patient and/or the patient’s family members in most cases. Patients and families can provide helpful information to the RCA² team as the team considers actions they think should be implemented to prevent a recurrence of the event. 

Patients and families involved in the event should not be members of the team because it is necessary to talk openly during team meetings. If anyone — patients, families, or staff — who was involved in the event participates in these discussions, other team members may refrain from speaking up or may self-censor what they say to spare these individuals from further mental anguish or to avoid hurting their feelings. 

The thoughts and perceptions of patients and families should certainly be considered in the ultimate recommendations of the team. But including them as part of the RCA² team would leave the team open to criticisms that the recommendations were unduly influenced by an inherent conflict of interest. Finally, the team should include a member who represents the patient and family voice (e.g., a patient representative) to bring that perspective to all the deliberations.

What is the best way to get leadership involved in the RCA² process?

With the RCA² guidelines, it is essential that the board and CEO are fully engaged in and supportive of the investigation and improvement process. It is the responsibility of the senior risk and safety leadership to inform and educate executives about the importance of the RCA² process and to illustrate how the process can lead to organization-wide improvements to safety. It is essential to emphasize the future risk mitigation that can result from a robust process. Presenting a “business case” for safety can also be a useful tool. One strategy to promote leadership engagement is bringing root cause analysis cases and action items to the highest level quality committee meetings as well as to board meetings, so leaders can truly understand the types of events occurring and the importance of a robust RCA² process.

You may be interested in:

• IHI Patient Safety Congress
• RCA²: Improving Root Cause Analyses and Actions to Prevent Harm