Ochsner Health System in Louisiana has transformed the way root cause analyses (RCA) are conducted.
Before 2015, the system, which is comprised of 13 owned or managed hospitals and over 60 neighborhood health centers, used a model for RCAs that, while very conventional, wasn’t as effective as it could be. Then, after attending a National Patient Safety Foundation (NPSF) meeting in 2015, Dr. Richard Guthrie, Chief Quality Office at Ochsner, learned about RCA².
RCA², short for Root Cause Analysis and Action, is a framework for root cause analysis endorsed by the NPSF. As the name suggests, the framework puts an emphasis on action – underscoring that discovering the cause of a problem is only useful if change happens as a result.
According to Jessica Behrhorst, System Director of Quality and Patient Safety at Ochsner, making the shift to RCA² was a natural solution to some of the challenges with the system’s existing RCA model.
“In the past, the way that we did RCAs was sort of the traditional way and [our quality staff] tried to be very thorough about them,” says Behrhorst. Under the old framework, anyone who was involved in an event would be called into a meeting. “It’s like getting called up to the principal’s office,” says Behrhorst.
The meetings, which could include as many as 50 people, were difficult to schedule and could be intimidating to staff. “We’d have people who would call in sick because they didn’t want to participate in an RCA meeting,” says Behrhorst.
The quality team at Ochsner also found it difficult to translate action plans into change on the floor without support from staff in the units. Learnings from RCAs were also not widely shared and, as a result, similar events would happen again.
With RCA² the approach is different – and so are the outcomes.
Staff directly involved in the event are no longer included in the official RCA meeting, and are instead interviewed ahead of time. “It’s not about ‘what you did wrong’,” says Behrhorst. “We’re really looking at the process.” This change in perspective reflects a larger move toward a just culture at Ochsner.
Other elements of Ochsner’s RCA² application include:
- Including staff from the unit where the event took place. This person isn’t someone involved in the event, but can provide perspective on processes in the unit.
- Having departments collaborate on their own RCAs, with the quality team taking an oversight or facilitation position.
- Performing RCAs on more than just sentinel events. These include events that never reach patients, like good catches and unsafe conditions.
But the most significant element of RCA² at Ochsner is exactly as the name suggests: action. The process is centered around creating causal statements that link together the causes of an event and the steps that need to be taken to address it. For example, Ochsner conducted an RCA on errors sterilizing surgical instruments. Previously these events, which never reached a patient, would not have even qualified for an RCA. But with RCA², the issue was analyzed and a point person was designated within the department to oversee the action plan, which ensured accountability.
Switching to RCA² has not been without challenges, but Behrhorst says that staff have been very engaged by the process. “I think people feel like this has become a less punitive process,” she says, “They feel like we’re actually taking things and fixing them and are not blaming a person, but addressing the process issues.”