Bryan Health has always been very attuned to the learning opportunities presented by root cause analysis (RCA) and case reviews of events. However, they realized that their previous method of conducting these reviews was weighed down by paper-heavy processes and could benefit from an update.
“There was a lot of paper involved before and as we started having our risk and feedback events in RL, the goal always was to have our root causes and case reviews stored electronically… we wanted it to be more easily accessible and more secure,” says Sue Corkill, Clinical Systems Analyst at Bryan Health.
Now, with the latest version of RL6: Root Cause, the team is hoping to make the RCA and case review process more seamless than ever.
Root cause analysis at Bryan Health
Bryan Health is a non-profit health system located in Lincoln, Nebraska bringing care to patients state-wide through mobile diagnostic and treatment services, telemedicine services, specialized heart care clinics, telehealth mental health counseling and more.
According to Elaine Thiel, Clinical Quality Improvement Specialist, the philosophy behind RCAs at Bryan Health is simple. “Our goal by doing these reviews is to improve our current processes and systems to keep our patient safe and also make it easy for our staff to do the right thing.”
RCAs are conducted when an event meets sentinel event criteria while case reviews are conducted for patient safety events that do not meet sentinel event criteria. Reviewing the case provides the opportunity to gain a better understanding of contributing factors and identify learning opportunities. On average, two or three RCAs/case reviews are conducted each month.
“Usually all of our RCAs and case reviews come to us via an event reported in RL6: Risk or there’s another file associated with it,” says Sue. “That’s very helpful because it keeps our files separate and people can work in both modules and not have to worry about overlap.”
At a very high level, their workflow includes:
- Inviting the people involved in the event to review what happened at the time
- Identifying corrective actions that can be taken
- Assigning an oversight person and target dates for the completion of the corrective actions
The team also identifies whether the corrective actions are applicable organization-wide and, if so, shares those via channels including Bryan Health’s newsletter.
At Bryan Health, the staff involved in an event are always invited to participate in the review process.
“We’ve found that there’s concern from the staff involved that people are going to place blame rather than review the issue”, says Sue. “I think that by reviewing the scenario with others they learn that it wasn’t just one action that caused harm to happen – there are usually contributing factors and even system issues that could be improved.”
The team at Bryan Health has found that involving staff throughout the review process has helped bring clarity to those involved and eliminate concerns of what is being said behind closed doors. Additionally, they’ve found that bringing the involved staff in leads to the most complete, accurate information.
Streamlining processes with RL6: Root Cause
Incorporating software has helped Bryan Health simplify and streamline their case review and RCA process – and they hope the latest updates to the software will continue to help them do so!
“We have a Patient Safety Organization (PSO) that we report to and our hope is that with the flexibility of the new root cause module we’ll get to the point that we can submit directly to our PSO,” says Elaine.
Having the ability to customize the module – even something as simple as changing picklist terms to reflect the Bryan Health terminology – has helped streamline the case review workflow.
Since the system is also using RL6: Risk and RL6: Feedback, they have also been able to capitalize on the integration between the modules – meaning that a lot of the data in a RL6: Root Cause file can be pre-populated.
“Having that information populate automatically definitely helps with workflow and increases consistency,” says Cyndie Hanson, Clinical Quality Improvement Specialist.
Always looking for ways to improve, the team is looking forward to seeing how RL6: Root Cause can grow with them – and how they can stretch the flexibility of the software to new limits. “I’m always trying to push the system to do different things and trying to make the system do what I want it to do,” says Sue, laughing, “Staying up to date with the latest release helps me do that, because I’ve got access to the latest features.”