This month we welcomed Jessica Behrhorst, System Director of Quality & Patient Safety at Ochsner Health System, to present a webinar on the transition they made to RCA2. Our audience had so many questions, that Jessica didn't have time to address them all in her presentation - so we sat down with her to get the answers to the rest of your lingering questions.
You can watch the full webinar, on-demand in our webinar collection.
How is the RCA team selected? Is it voluntary or are they volun-told?
Jessica: It’s a mix of both. Usually we find people who we think would be appropriate for the RCA. We’ll try to get them to volunteer – sometimes schedules can be challenging, especially for physicians. But for the most part we’ve found that people have been very eager to participate.
What do you attribute this eagerness to participate to?
Jessica: I think now that we have changes the process, people are eager to see how the process is going. I think most people want to have the opportunity to be a part of the improvement.
Can you just implement parts of RCA2 over time or is it best to scrap the current RCA process and go full force into RCA2?
Jessica: It’s best to kind of go full force. There are some parts that you can ease into. As we implemented RCA2 some of our facilities had troubles letting go of the entire RCA process so they eased into it in some ways. But as far as changing the tools and changing the rules around RCA, you just have to jump in.
How do you ensure that the RCA2 is kept confidential under QA, for protection purposes - with so many people involved?
Jessica: It’s a small group of people that are involved in the RCA. We do report out, but once we’re at that stage the information is de-identified. And because RCAs are part of our peer review process in Louisiana, we have a good peer review statute that protects the RCA process because it’s done for evaluation.
What are some specifics on your 'good catch' process?
Jessica: For our good catch process, we did it in the RL form, it's just a much shorter form. Our regular forms can go up to 45 fields, our good catch form has 15 fields. So it's just a very quick form. We did the good catch as a general occurrence type, that way if we get something submitted that is not actually a good catch, but that's actually an event that happened, we can change the general occurrence type to a different type of event.
How much time lapses between the event and the RCA2?
Jessica: Ideally, the RCA is completed within 45 days of the event being reported. We meet this timeline for most events, particularly because for our high severity events it is a Joint commission requirement.
RCA is very resource intensive, especially the Action Plan part. How did you cope with that?
Jessica: Part of the leadership buy in was making sure that we had the resources or that we could use the resources to do it, we know that it is very resource intensive and so, part of it is just getting that leadership buy in. For our clinical staff, for example, that might be involved in an event, we make sure that they are given the administrative time to participate.
After completing your RCA, how does your team provide feedback to the frontline clinicians who were involved in the event?
Jessica: Ideally, the leader of that team will provide feedback based on the RCA, we have sort of the documentation piece of it in the RL tool but our hope, what we think is happening with most teams is the leader is providing feedback to the staff members.
When action recommendations involve evaluating a new product, expansion or change in existing services, etc. (substantial consideration/evaluation for an improvement in what already exists), how should those action recommendations be approached/written?
Jessica: We have a six month follow up and at the initial 60-day follow up, we talk about what barriers might be. This allows us to engage with the groups we need to remove those barriers – for example if we know the process needs to include out surgery integration council, but they only meet once a month. The reason we present them at this sort of our system quality council, is because we have sort of senior level decision makers in there that can help.
