Conducting A Root Cause
Analysis
Nina Shik, MSN, RN, NEA-BC, CIC
Director of Epidemiology
North Shore University Hospital
Manhasset, NY
North Shore University Hospital
NSUH is an 804-bed quaternary teaching hospital in Manhasset, NY.
NSUH is a Level 1 Trauma Center with 5 Adult ICUs and a Level-3 NICU.
It is the largest hospital in the North Shore-LIJ Health System.
My Role
• 22 years of experience in Infection Prevention
• Director of the NSUH’s Infection Prevention
program since November 2012
• Report to Hospital’s Associate Executive
Director of Quality and System VP of Infection
Prevention
• Lead a team of 6 Infection Preventionists
• Work with IPs from across the NS-LIJ System
Root Cause Analysis (RCA)
• RCA is a systematic, formalized approach to
review an adverse event and identify root
causes
• RCA provides a forum for key individuals to:
– focus on a problem
– come to consensus about factors leading to
the problem
– develop effective corrective actions
Root Causes
• Specific factors leading to adverse events
• Help identify what, how and why an event
occurred
• Are specific and based upon factors that can
be modified
• Identifying “snow storm” as the reason staff
were not available to provide patient care is
not specific enough. We can’t control the
weather.
Not a “Stand Alone” Solution
• RCA is a strategy that complements other
quality improvement activities
• RCA is most effective within a comprehensive
safety program
RCA Steps
• Develop a core team that is invited to every
RCA. For an HAI RCA this includes:
– Chief Medical Officer, Associate Executive Director
of Quality, Infection Preventionists, Infectious
Diseases Chair and the Medical and Nursing
Directors for area being reviewed
• For each meeting invite other participants
depending on type of issue being addressed
– Always include care providers who were involved
in event
– Cast a wide net
Before the RCA Meeting
• Outline a step-by-step process leading up to, during
and after the RCA meeting, including:
– Who leads the meeting
– Who takes minutes
– Who provides patient information during the RCA and
what information they are expected to share
– Who researches and shares applicable standards for care
– Who develops action items, based upon root causes
– Who implements the action items
– Who collects data to determine efficacy of interventions
– How to determine if interventions are effective
Before our Meetings
• IP identifies HAI, based on NHSN definitions
• Nurse Manager review patient record to
determine who should attend RCA
• IP Director contacts the attending physician
and Chair of Infectious Diseases to discuss the
event and the RCA process
• IP Director sends list of meeting participants
to Quality Department
• Quality organizes the meeting and invitations
During our Meetings
• Chair of Infectious Diseases chairs the meeting
• Attending Physician presents the patient’s
case
• Infection Preventionist presents the HAI
history
• Care providers present patient-specific HAI
clinical information
• The group discusses the case and identifies
causative factors
At the End of the Meeting
•
•
•
•
The Chair summarizes discussion points
The group determines action items
The action plan is written down
Goals are established (e.g., decrease CAUTI on
the unit by 50% in the next 3 months)
• Data collection method is determined
• Follow up time frame is established
After the Meeting
• Action plans are implemented
• Follow-up data are collected
• Data are reviewed and share with key players
and relevant committees
• If results are positive we may decide to spread
the interventions to other units
• If results are not as hoped we conduct
additional RCAs
Getting to the Root Cause
• Make sure that the right people are in the
room
• Ensure a safe, non-punitive environment
• Start with an overview of the processes
related to the event
• Focus on issues, not individuals
• Let everyone provide input, but keep the focus
on the event and related processes.
Questions to Consider
• What happened?
• When and where did the occur?
• What are usual, recommended
processes/practices for this type of
care/device/procedure?
• Were all steps followed, in the correct order?
• Were all providers trained and competent?
• Are there other factors to bring up?
Helpful Tools
• Fishbone diagram is helpful to keep focus on
evidence-based risk factors.
• Fishbone “spines” often include:
– Patient-specific factors
– Caregiver factors
– Equipment factors
– Environmental factors
– Systems factors
Pre-populated Fishbone
• If factors contributing to a problem are well
defined in the literature it may be helpful to
use a prepared Fishbone Diagram that
includes these factors
• Contributing causes of CAUTI are wellrecognized, so we use a pre-populated
Fishbone for CAUTI RCAs that IPRO provided
• It ensures a consistent review and
consideration of all relevant risk factors
IPRO CAUTI Fishbone
“5 Whys” of Problem Solving
• Using 5 Whys helps us to think beyond
obvious “gut feeling” aspects of a problem to
get to root causes
• Allows different ideas to be expressed
• Encourages every participant to provide input
“5 Whys” Example
• Why do you think the CAUTI occurred?
– The catheter was left in longer than needed
• Why?
– An order to remove it was not written
• Why?
– The nurse and doctor forgot to discuss the need for the
catheter during rounds
• Why?
– Their rounding tool does not address urinary catheters
• Why?
– The tool was just revised and the urinary catheter daily
assessment section was inadvertently deleted
Action Plan
• You may identify several root causes
• Suggestions for improvement should be
discussed for each one
• By the end of the meeting a list of action
items should be developed, with identified
“champions” and a time line for completion
• Some items may need to be addressed by a
smaller working group or hospital
administrators
Support and Follow-Up
• A high level of energy usually occurs after a
successful RCA
• Staff are motivated to make identified changes
– Provide resources to support them
– Collect data to determine if the changes are
effective
– Share data with RCA participants
– Celebrate successes!
Benefits of RCA
A successful RCA program:
• Increases collaboration and sharing of
information
• Allocates resources to meaningful root causes
• Encourages accountability and follow-up on all
levels
• Identifies solutions to share with other areas
of your facility/system
• Promotes a culture of safety
NSUH CLABSI RCAs
• Part of a comprehensive CLABSI prevention
initiative
• Rates decreased, but did not reach zero until
RCA’s were formalized and expanded to
include more physicians
• At a recent luncheon to celebrate zero CLABSIs
our Chair of Infectious Diseases remarked that
the best thing about zero CLABSIs, in addition
to patient benefits, was not having to attend
RCA meetings!
Numbers of CLABSI by Month
7
6
5
4
3
2
1
0
RCAs
began
RCA process
formalized
RCA membership
expanded
References
• Rooney, J. J., & Heuvel, L. N. V. (2004). Root cause
analysis for beginners. Quality progress, 37(7), 45-56.
• Zidel, T. G. (2006). A Lean toolbox: Using Lean
principles and techniques in healthcare. J Healthc
Qual, 28(1), W1-7.
• IPRO Root Cause Analysis Toolkit qio.ipro.org/wpcontent/.../12/7_1-12-14_RCA_Toolkit_final.pdf
Questions?
Thank you for your attention
I can be contacted at nshik@nshs.edu