Root Causes, Actions

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Root Causes, Actions and Outcome Measures
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Why create Root Cause statements?

• Its not a grammar exercise
• Root Causes explain the teams findings about
  what must be fixed
• Root Causes guide everything else that follows
  (task assignment, actions, outcome measures)
• Strong Root Causes set up success

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Why create Root Cause statements?

• Weak Root Causes undo everything
• Two worst case scenarios
• - do-overs
• - no root cause, everything that should
  have been done, was done

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Where do teams get stuck?

• Lack of information (e.g., few interviews, few
  references, limited or no simulation, limited
  time, etc.)
• Focus on too big a problem (saving the world)
• Focus on too narrow a problem (saving one
  particular patient)
• Being overwhelmed by events that tend to occur
  frequently (before actions have a noticeable
  effect)

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How to get teams un-stuck

• Do more interviews
• Check the literature
• Check with professional colleagues (contact
  similar facilities in different parts of the
  country)
• SIMULATE the event
• Find the time to do the best job possible (thank
  and replace team members that are not able to
  commit)

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• Stick to/focus on the situation at hand
  (unrelated findings can be delegated to others)
• Look at tragedy without staring (focus on what
  can be done to help other patients, families or
  staff in the future)
• Select bite-sized actions/outcome measures for
  events that you know occur frequently (look for
  volunteers, use short cycles of change, fix one
  thing at a time)

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Make it easy to do

• Read the Triage flip book 5 Rules of Causation
• Brainstorm first, then take the plunge and throw
  some words onto a flip chart (edit, later) be
  factual and specific
• Compare each Root Cause statement with the 5
  Rules

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A short version of the 5 Rules

• Show Cause and effect
• Nothing negative about people
• Fix systems, not people
• Fix norms, not people
• Duty to act

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ROOT CAUSE STATEMENTS

• A closer look at the 5 Rules some examples

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Rule 1. Clearly show the cause and effect
relationship.

• WRONG A nurse was fatigued.
• CORRECT With overtime, nurses are often
  scheduled more than 40 hours a week as a result,
  fatigued nurses are more likely to misread tube
  insertion instructions. (This could take us to
  new workload arrangements, bigger/clearer
  instructions, different/easier to use tubes, etc.)

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Rule 2. Use specific and accurate descriptions
of what happened, rather than negative and vague
words.

• Avoid words such as wrong, bad, poor, failed,
  careless, etc.
• WRONG Poorly written procedure.
• CORRECT The restraint procedure has 8 point
  font and no illustrations so staff dont use it,
  increasing the likelihood that restraints are
  applied incorrectly. (This takes us to actions
  like bigger typeface, use of photos, etc.)

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Rule 3. Identify the preceding cause(s), not the
human error.

• WRONG Staff did not notice the patient was
  missing for at least 8 hours.
• CORRECT Due to a malfunction in the door/vest
  wandering alarm, a patient was able to elope
  undetected. (This takes us to actions like )

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Rule 4. Identify the preceding cause(s) of
procedure violations.

• WRONG Week-end staff did not follow the policy
  for dressing changes.
• CORRECT Due to a shortage of supplies over the
  week-end (dressings, and cleansing solutions)
  dressings were not changed as frequently as
  policy requires. (This takes us to actions like
  )

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Rule 5. Failure to act is only causal when there
is a pre-existing duty to act.

• WRONG The nurse did not check for STAT orders.
• CORRECT The absence of an assignment for nurses
  to check for STAT orders increased the likelihood
  that STAT orders would be missed or delayed.
  (This takes us to actions like )

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ACTIONS

• Be specific and clear
• Give them to a cold reader to see if they make
  sense
• Specifically address the root cause (you want to
  prevent the situation from happening again)
• Test the actions or simulate process changes
  before facility-wide use
• Check with the process owners (dont blindside
  middle managers interview them for suggestions)

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Some Actions
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OUTCOME MEASURES

• Outcome measures tell you if the action has made
  the situation better (or if it has stayed the
  same, or gotten worse)
• Be specific and quantifiable use numerators,
  denominators, and thresholds.
• State how many things youre going to check, and
  how often youre going check (e.g., check 10
  charts every week, re-assess 5 patients every
  month, etc.)