Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient Safety

David Allison, CPPS, has 15+ years of facilitating RCA teams, and teaching RCA methodology for patient safety and risk management professionals. He has over 30 years of experience in healthcare and has provided leadership in behavioral health, risk management, and patient safety settings. David has been the process owner for the safety value stream across a healthcare system, helping to reduce the rate of serious safety events with tools such as RCA. Harold Peters, P.Eng., is an improvement professional with extensive experience in healthcare, service, government, and manufacturing. During his 15+ years in healthcare, he led Lean project and transformation work, facilitated RCAs, and introduced other improvement methodologies like Work Simplification, Theory of Constraints, and Operations Research. In system leadership roles, he established and led the process improvement strategy, structure, standards, and resources for two large healthcare systems across multiple states, and led the system patient safety department in one of the organizations, developing strategy, structure, standards, and teaching RCA methodologies.

• Part 1: Building an Understanding of RCA. 1. The Need for Root Cause Analysis (RCA). 2. Forms of Analysis. 3. Pre-Work for an RCA Team Meeting. 4. Creating the Logic Tree. 5. Effective Action Plans. 6. RCA Facilitation. Part 2: Root Cause Analysis Champions. 7. RCA Standard Work by Role. 8. Barriers to RCA and Their Countermeasures. 9. Strategies for No Repeat Events. 10. Teaching RCA.

"The main strengths of the materials are that they are practical, thorough and readily applicable to healthcare. The materials provide tools necessary for successful RCA performance and action plan implementation based on the authors years of experience leading the analysis of actual patient safety events in healthcare. The materials emphasize the importance of learning from adverse events to an organization’s culture of safety. The authors place the patient at the center and also recognize the importance of credible event investigation to caregivers. The materials appropriately emphasize a systems approach to medical errors, the importance of reliably identifying the root cause of an event and implementing an action plan that prevents the error from recurring."- Andrea Halliday, MD, Former Chief Clinical Officer Peace Health and PeaceHealth Oregon Network CMO (retired)