by Robert J. Latino, CEO of Reliability Center Inc.
Whenever an organization seems to adapt ‘RCA’; when the organization does not produce overall results, they attribute it to RCA not working. Seems logical right?
There over around 6,000 hospitals in the U.S. and 95%+ are accredited via various accrediting agencies. We know this because they are proud of this accreditation and put up their certification in the front lobby to let the patients and families see and gain confidence in that accreditation. Part of this accreditation process involves accrediting their RCA programs and their ability to meet the agency’s requirements.
So if the majority of hospitals in the U.S. have accredited RCA efforts, why do the overall patient safety numbers continue to slide? Is it a logical deduction that RCA compliance does not equal patient safety? Shouldn’t compliance equal patient safety? We should do a valid RCA on this dilemma:-)
So why isn’t RCA working effectively in HC, when it is has been field-proven in other industries for decades?
Whenever anyone is time pressured, they will likely opt for the path of least resistance. It’s human nature. Caregivers no doubt are very busy people and we should respect that because their ‘product’ is the quality of our lives. Most of us work in businesses that make widgets or provide other types of services, but we are not responsible for quality of life like those in hospitals.
How does this time pressure affect RCA? It is very likely the overwhelming majority of caregivers did not go to school to learn how to do RCA. It was likely not included in their curriculum at all. So when faced with a regulatory/standards requirement to do it, this is often viewed as another burden on my already full plate.
So I think to myself, how do I quickly satisfy this compliance requirement with the least impact on my ‘real job’? This is the thinking that leads us to the path of “Shallow Cause Analysis” (SCA). Success to me, at this point, is compliance. Actual patient safety is a pipe dream. This is because the time to do an effective RCA is taking me away from my patient time…isn’t this contrary to my purpose here in the hospital?
This reminds me of a saying:
“We never seem to have the time and budget to do things right, but we always seem to have the time and budget to do them again”
This pushes us to take shortcuts in our analyses in the interest of providing more care to the patient and in my next blogpost I’ll describe common ones and how they impact an RCA.
Part II: Shortcuts in RCA
Part III: Why RCA Efforts Fail
Robert J. Latino, CEO of Reliability Center Inc., (RCI). RCI is a Reliability Consulting firm specializing in improving Equipment, Process and Human Reliability. Mr. Latino received his Bachelor’s degree in Business Administration and Management from Virginia Commonwealth University.
Robert has been facilitating RCA & FMEA analyses with his clientele around the world for over 29 years and has taught over 10,000 students in the PROACT® Methodology. Mr. Latino is co-author of numerous seminars and workshops on FMEA, Opportunity Analysis and RCA as well as co-designer of the national award winning PROACT Suite Software Package.
Reliability Center, Inc. Hopewell, Virginia Tel: 804.458.0645 Fax: 804.452.2119 www.Reliability.com
Recently Authored or Co-Authored Books:
Latino, Robert J., Latino Kenneth, C. and Latino, Mark A. Root Cause Analysis: Improving Performance for Bottom Line Results. 4th Ed., 2011, c. 280 pp., ISBN: 9781439850923, Taylor & Francis. Boca Raton.
Latino, Robert J. Patient Safety: The PROACT Root Cause Analysis Approach. 2008, c. 272 pp., ISBN 9781420087277, Taylor and Francis. Boca Raton.
Contributing Author: Error Reduction in Healthcare: A Systems Approach to Improving Patient Safety. 2nd ed, 2011 [Apr], c. 284, ISBN: 1-55648-271-X, AHA Press.
Contributing Author: The Handbook of Patient Safety Compliance: A Practical Guide for Health Care Organizations. 2005, c. 350 pp. ISBN 0-7879-6510-3, Jossey-Bass .
Authored or Co-Authored Papers:
Latino, Robert. (2013). Improving Reliability with Root Cause Analysis. Patient Safety & Quality Healthcare. September/October 2013.
Pil, Tricia MD. (2010). Follow Up:A Deeper Look at Root Cause Analyses. Science and Sensibility Blogpost, Published response by Robert Latino 11/29/10.