RCA for WEMIC May 2013.pptx

How to Perform a
Worthwhile RCA
Martin Kiernan
Nurse Consultant
Southport and Ormskirk Hospital NHS Trust
@emrsa15
2
This session
¡ Objectives
¡ Why do one?
¡ When it is useful (and when it isn’t…)
¡ Who should take part
¡ What does a good outcome look like?
¡ How can RCA improve patient care?
¡ Not to tell you how to suck an egg
What is ‘root cause analysis’?
¡ A problem solving process for conducting an
investigation into an identified incident, problem,
concern or non-conformity
¡ systematic investigation technique that looks beyond the
individuals concerned and seeks to understand the
underlying causes and environmental context in which
the incident happened
¡ NPSA 2004
Quarterly MRSA Bacteraemia
England: 2001-12
2500
2000
1500
1000
500
0
Surveillance
4
Quarterly C. difficile
England >2y: 2004-2011
18000
16000
14000
12000
10000
8000
6000
4000
2000
0
Surveillance
5
6
Change in Bacteraemia
2002-2011
30000
25000
20000
15000
10000
5000
0
E. coli
S. aureus
Klebsiella
Seasonal trends in cause of bacteraemia: 2004-­‐2008 5,000
4,500
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
2004.1 2004.2 2004.3 2004.4 2005.1 2005.2 2005.3 2005.4 2006.1 2006.2 2006.3 2006.4 2007.1 2007.2 2007.3 2007.4 2008.1 2008.2 2008.3 2008.4
Year and quarter
E. coli
S. pneumoniae
Klebsiella spp
Pseudomonas spp
Wilson et al Clinical Micro Infect, Sept 2010 Seasonal trends in cause of bacteraemia: 2004-­‐2008 1,500
1,000
500
0
2004.1 2004.2 2004.3 2004.4 2005.1 2005.2 2005.3 2005.4 2006.1 2006.2 2006.3 2006.4 2007.1 2007.2 2007.3 2007.4 2008.1 2008.2 2008.3 2008.4
Year and quarter
Klebsiella spp
S. pneumoniae
Pseudomonas spp
Wilson et al Clinical Micro Infect, Sept 2010 9
Root Cause Analysis
¡ Is it starting to become ‘yesterday’s thing’?
¡ Quality circles, TQM, Board to Ward, ‘Lean’ etc etc etc
¡ All of these things eventually fail and are no longer used
¡ Until they get ‘reinvented’..
¡ Why?
¡ Because they are never fully embraced throughout the
organisation
¡ Embedding does not occur
What infection-related
incidents should be looked at?
¡ Serious incidents
¡  events that may have resulted in permanent serious harm,
unexpected death, or ‘near misses’
¡  Object is to ensure that opportunities to prevent re-occurrence
are not missed
¡ Examples:
¡  Healthcare-acquired bacteraemia
¡  Device-related
¡  But not just device-related
¡  SSI
¡  CDI
11
The problem
¡ Ever looked at a root?
¡ What happens if you do
not remove the whole
root?
12
The Pre-RCA era
¡ ICT look at cases
¡ Rapid
¡ No committee
¡ No summons
¡ No interest
¡ No action (unless the ICT did it)
Case History - 2002
¡ 89 year old admitted ‘unwell’, not walking
¡  Recorded as admitted from own home
¡ Admitted to medical ward
¡  unable to weight bear; ‘off her legs’
¡ Then someone saw the externally rotated and
shortened right leg…
¡  Fractured femur 3 weeks before
¡  Internally fixed with standard prophylaxis
¡ Wound infection and fatal sepsis 7d later
What really happened
✗ Patient was actually admitted from a nursing home
with endemic MRSA but PAS listed her as from own
home
✗  this was recorded in the medical notes: no-one informed
✗ As she was admitted to a medical ward and not an
orthopaedic ward she did not have a routine screen
✗ No-one knew (or suspected) that MRSA may be an
issue
✗  No suppression prior to surgery
✗  Inappropriate antibiotic cover
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You have a problem
and you are going to
fix it
We have a problem,
how will you fix it?
Solution
We have a problem,
how do we fix it?
Do we have a
problem? How
should we fix it?
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Cause and Effect
Ishikawa (1968)
¡ Categories normally included:
¡ People
¡ Methods: How aprocess is performed and requirements
for doing it, such as policies, procedures, etc
¡ Machines: Equipment, computers, tools, etc.
¡ Materials: Raw materials used to produce the final
product
¡ Measurements: Data that are used to evaluate quality
¡ Environment: The conditions, such as location, time,
temperature, and culture in which the process operates
Maidstone & Tunbridge Wells NHS Trust
>1000 patients infected; 90 deaths
Healthcare Commission report
¡ People (+ Environment)
¡ Board unaware of high rates; culture focused on other
targets (A&E)
¡ Shortage of staff; poor hand hygiene & patient care,
training not happening/effective
¡ Environment (+Methods)
¡ Bed occupancy >90%, frequent ward movements
¡ Environment
¡ Substandard cleaning, beds spacings
Ishikawa approach (Fishbone)
Organisationwide issues
Task
Delivery
issues
Equipment
& resource
issues
Working
conditions
issues
Problem
Communication
issues
Education
& training
issues
Team &
social issues
Patient
issues
Using a Fishbone
¡ Incident is the endpoint
¡ Examine each aspect and determine potential causes for
the event, followed by the causes for those causes, etc
until no more possible causes can be determined
¡ These are the root causes
¡ You will find several root causes
¡ Prioritise the issues most likely to be responsive to action
that will have significant impact
¡ Look for common themes and escalate
Contributory factors
What do you need?
¡ The RCA investigation group
¡ Competent
¡ Credible
¡ Knowledgeable (about the patient and the incident)
¡ Objective
¡ Organised
¡ Trained in RCA (?)
¡ Is this the right terminology?
Who do you need?
¡ Those who KNOW what happened
¡ One junior clinician and a matron sitting in an office
reviewing the notes a couple of weeks later will NOT do
¡ Ask
¡ Who was there?
¡ What were they doing?
¡ Why were they doing that?
¡ When do you need them?
The Toddler Approach
¡ Why?
¡ Ask why
¡ The answer to the first ‘why?' will prompt another ‘why?
¡ The second ‘why?' may prompt another why?
¡  This ‘why?' may prompt another why?
¡  This ‘why?' may prompt another why?
¡  This ‘why?' may prompt another why?
¡  This ‘why?' may prompt another why?
¡  This ‘why?' may prompt another why?
¡ 
This ‘why?' may prompt another why?
¡ Eventually you have to find a satisfactory answer
25
HAIR
¡ Healthcare-associated Infection Review
¡ ICO organisation
¡ All bacteraemia >48 hours after admission
¡ Undertaken on the first ward round after the case
has been detected
¡ MDT review
¡ Relationships are key
26
Building Relationships
¡ Generally we only see colleagues when it is bad
news
¡ For the patient or them
¡ Participation in post-take ward rounds is useful
¡ Seen as advisors
¡ You can see all sorts of things as you become ‘invisible’
27
Recent HAIRS
¡ E. coli bacteraemia related to catheterisation for
retention
¡ No organisms in urine 10 days before
¡ S. aureus bacteraemia related to parotitis
¡ No sign of this as an issue 7 days before
¡ Same ward
¡ Anything similar?
¡ Both were dry as a crisp
28
CDI RCAs
¡ Personal feeling is that this is risk factor analysis
¡ MRSA bacteraemia is easier
¡ Don’t know
¡ Transmission route relative importance
¡ Incubation period
¡ Number of orgs for transfer
¡ Etc etc etc
¡ Lots of Abx activity in Hospital and Community
29
MRSA Bacteraemia
¡ Concentrate on
¡ 48 hr or so prior to bacteraemia
¡ Device management and manipulations
¡ Healthcare interventions
¡ Need to do it asap
¡ The notes are rubbish and the hospitals are full of locums
and nurses who are just back after
¡ But then look back – where did colonisation
occur? (or what’s your best guess..)
30
Where do the results go?
¡ Where the actions will be monitored
¡ Little point in reporting to a committee that is just a talking
shop
¡ Infection Prevention and Control Committee..
¡ Restructured (thanks to Mike Cooper)
¡ Takes no more than an hour, chaired by CEO
¡ Receives reports from Divisional IPC Groups and
scrutinises action plans based on performance reports
and RCAs
31
Post-infection Review
RCA GT Turbo
¡ An attempt to get people who do need to speak to
each other to do just that
¡ Concern over advice in non-acute settings
¡ Enough of the ‘it’s yours’ PLEASE
¡ A significant number of ‘Community’ CDI patients have
recently been discharged from an acute hospital
¡ 100% of ‘Hospital’ CDI patients have been
admitted from the community..
¡ Early personal evidence is that this isn’t working
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Patient Feedback
¡ Why Not?
¡ Disclosable anyway
¡ Transparency could bring trust but would clinicians
be comfortable with this approach
¡ Would this mean an even more defensive position
¡ Nebraska Medical Centre approach
¡ RCA done in the ITU at the patient’s bedside
33
Key Points
¡ Don’t fall into the trap of thinking the problem and
therefore the solution is obvious
¡ Ensure improvements that you can implement are
owned and signed up to by the team (or
importantly the team they affect)
¡ Ensure that you only end up taking responsibility
for actions you have control over
¡ Ensure that someone is taking an organisationwide overview
34
Meaningful RCA
¡ But to whom?
¡ Commissioner/External scruitineer
¡ Management?
¡ Staff?
¡ The Patient?
¡ You?
¡ Nothing matters unless it is personal
¡ A meaningful RCA is one that provokes ACTION