Why It Matters
One of the things that makes me passionate about patient safety is understanding the human toll of harm on our patients and their families. When patients think about receiving health care in a hospital or a clinic, they expect to be safe. They trust that they will get better, not sicker.
While I know many of my colleagues in health care feel the same way, it is worth highlighting why developing a safety culture can be so challenging. For example, people can (sometimes justifiably) fear a range of responses if they speak up about adverse events or unsafe conditions:
- Retribution or other negative consequences
- Not being taken seriously
- Nothing changing despite reports of problems
- Being seen as a “tattler”
- Their team being seen in a negative light
To create a safety culture requires acknowledging and addressing fears like these. In a safety culture, people can speak up without fear of punishment, job loss, or damage to their credibility. In a safety culture, people look out for harm so they can proactively address problems in the system. Reports of problems are taken seriously and lead to change in a safety culture.
Identifying an error can feel like “tattling” if we think of it as reporting on a person instead of reporting an event. When we focus our attention on the error itself and what needs be fixed in the system, we help to build a culture of safety and a culture of improvement.
IHI Redesigning Event Review with Root Cause Analyses and Actions (RCA2)
Learning safety culture behaviors goes beyond individuals. To build positive group norms around reporting, we must help teams reframe the work as improvement focused on reducing error and increasing safety rather than singling anyone out for punishment or shame. This can help engage teams in the process of fixing problems rather than putting them on the defensive.
In a safety culture, people make behavioral choices and ask key questions to keep patients safe: Do we behave professionally and respectfully in how we relate to each other? Do we allow open discourse and dialogue? When there are errors in the system, are we fixing them instead of ignoring them? Are we using improvement principles to build a better and safer system and not punishing individuals?
How Root Cause Analysis + Action Can Address Fears
Root Cause Analysis + Action (RCA2) is one important tool for addressing common fears regarding safety. For example, many people who have gone through the typical RCA have not felt psychologically safe during the process. In too many cases, organizations do little with the results of an RCA.
RCA2 improves on the traditional Root Cause Analysis process by focusing on processes and systems (and not on individuals) to support psychological safety and by developing a plan of action after determining root causes. RCA2 takes individual blame out of the RCA process, and helps teams create sustainable solutions.
To ensure that solutions “stick” requires finding the most meaningful ways to make improvement. This is why a key part of the RCA2 process is to use the action hierarchy to identify weak actions, intermediate actions, and strong actions to promote safer systems.
Measurement is another key to sustainability. It makes no sense to build an action plan, put it in a binder, and not check on it again. Instead, we must think about the individual actions necessary for improvement, and the process measures and outcome measures needed to determine the impact of those individual actions. Measurement helps us know when a change is an improvement and creates accountability.
Replacing Fear with Engagement
When people are involved in adverse events, part of how we engage them in problem-solving is by avoiding individual blame and tapping into their natural desire to help prevent the error from ever happening again. It has been gratifying to hear from people who have been part of RCA2 after going through a typical RCA. They were often surprised that RCA2 does not mean going into a room where everyone is going to point out somebody else’s mistakes.
People who have taken part in RCA2 often remark on how much more participatory it was compared to the traditional RCA. They were eager to be asked for their input to determine what in the system broke down that allowed mistakes to happen. They were pleased to be part of a process to help create a safer system for everyone.
Jessica Behrhorst, MPH, CPPS, CPQH, CPHRM, is Senior Director, Patient Safety at the Institute for Healthcare Improvement (IHI). She is faculty for IHI’s Patient Safety Executive Development Program.
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RCA2: Improving Root Cause Analyses and Actions to Prevent Harm