by Robert J. Latino, CEO of Reliability Center Inc.
In previous posts (RCA has a Public Relations Problem and Common RCA Shortcuts & Outcomes)I’ve described why providers may take short cuts in doing an RCA and what common shortcuts are. Sure, we can say we’re in “compliance” because we’ve done the RCA, but such efforts are more like ‘Shallow Cause Analysis” (SCA) and they are not helping us solve the problems we’re facing with patient safety!
These are the six reasons why RCA efforts fail:
1. Little to no corporate expectations for the effectiveness of the RCA effort (no tie to patient safety). Who knows their ROI’s for their RCA effort?
2. Inadequate management support and lack of proper infrastructure to support RCA analysts
3. Inadequate training in effective RCA methods and tools. We do the best with what we have and cannot afford tools that make it easier to perform the analyses and compile the information.
4. Lack of accountability for implementing corrective actions and tying them to a quantifiable patient safety metric (compliance alone is often the end game). Is anyone held accountable for an RCA effort to close the gap in unacceptable patient safety metrics?
5. Lack of adequate resources provided to the analysts to make conducting the analyses easier and more comprehensive (e.g. – technology solutions, conference rooms with proper A/V, etc.)
6. Lack of adequate policies and procedures to support RCA (they are written for compliance and not directed at patient safety). When I try to get the docs to participate, this is viewed beneath them. I cannot cite a policy that requires them to participate. If there is no negative consequence for not participating, why should they?
When we look at our own RCA efforts, how can we prove their effectiveness on actual patient safety? If we can’t, why can’t we? Are we so busy (reactive) that we do not have time to prevent (proaction) the very things that we have to react to?
There are nearly 6000 hospitals in the U.S. and most all are accredited by some deeming agency. However, since the enlightening IOM report of 1999 stating that medical errors kills 44,000 – 98,000 patients per year, medical error rates have not overall, improved. Many reports indicate they are actually on the rise. Why? How could most all of our RCA efforts be accredited and patient safety worsen?
It is easy to blame the RCA methodology or the RCA tool. However, that is often a scapegoat to face the realities of our own systemic flaws that prevent our RCA success. While ‘Shallow Cause Analysis’ may be acceptable to the recipient of the report, the true measure of effectiveness should be how is the patient better off (and not that we are ‘compliant)?
If the success of our RCA’s is measured by our direct impact on the patient, regulatory compliance will be a by-product. What is required is that the quality of our RCA’s must exceed the minimum requirements of the regulations and standards in place, in order for us to improve patient safety. We just have to have the courage and fortitude to admit it and do something about it.
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.