Why Does Healthcare Root Cause Analysis Fail?

Study Points to Problems

A study carried out by researchers in Spain on data from around the world (How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review) concluded that:

“…root cause analysis is a useful tool for the identification of remote and immediate causes of (patient) safety incidents, but not for implementing effective measures to prevent their recurrence.“

The conclusion was reached after the researchers reviewed 21 previous independent studies of the effectiveness of root cause analysis in the healthcare industry.

The researchers stated that:

“The literature collected analysed the usefulness of RCA as a process that allows the determination of factors that contribute to the occurrence of AAEs. Most of these were caused by communication problems among professionals, human error and, finally, faults in the organisation of the healthcare process.“

In reviewing the study, I had several concerns about why healthcare root cause analysis fails to produce adequate results (finding and eliminating the causes of patient safety incidents). I will discuss my concerns about healthcare root cause analysis in the sections below.

What is Root Cause Analysis?

What is root cause analysis? Here is our definition:

“The process of finding the missing
best practices or knowledge
needed to prevent a problem.”

We detailed this definition in THIS ARTICLE. Note that the process of root cause analysis is not mentioned in the definition. However, the devil is in the details of how a root cause analysis is performed. And as Admiral Rickover said:

The study talked about “root cause analysis” like it was a single, standard process. It isn’t.

Root cause analysis in the healthcare setting is usually an unsystematic process performed by people in an environment full of blame who have had little or no training in effective root cause analysis. This often leads to inadequate analysis, identification of symptoms rather than root causes, and inadequate corrective actions (the “missing best practices or knowledge needed to prevent a problem” mentioned in the definition above).

Let’s talk about several healthcare root cause analysis techniques that we believe are unsystematic or in other ways, compromised.

Healthcare root cause analysis often uses substandard root cause analysis techniques including 5-Whys, Checklists, Cause and Effect Diagrams, Brainstorming, and Fishbone Diagrams. Why do I call these substandard techniques? You can read about why we believe these techniques are substandard in these articles:

• Root Cause Analysis “Under Scrutiny”
• Comparing 5-Whys with Advanced Root Cause Analysis
• Fishbone Diagram Root Cause Analysis – Pros & Cons
• What’s Wrong With Cause-and-Effect, 5-Why’s, & Fault Trees
• “Fast” Root Cause Analysis: Brainstorming, 5-Whys and Fishbone Diagrams

Many common root cause analysis techniques used in the healthcare industry fail to meet the fundamentals required for good root cause analysis. These fundamentals are outlined in THIS ARTICLE.

Because they don’t meet the fundamentals of root cause analysis, they have the following three major problems:

1. They often focus on a single cause (rather than the multiple causal factors for most patient safety incidents).
2. They promote confirmation bias for the investigator or the investigation team.
3. They provide little or no guidance to the root causes of human errors (they don’t guide investigators beyond their current knowledge to the causes of human errors).

The third problem mentioned above seems to be confirmed by this statement in the research study:

“The most common causes involved in the occurrence of AEs (Adverse Events) were communication problems among professionals, human error, and faults in the organisation of the health care process.“

Note that the study notes that “human error” is one of the three most common causes identified in healthcare root cause analyses. This confirms my belief that the common tools in healthcare root cause analysis do not guide investigators beyond “human error” to the true root causes of human performance issues.

Blame

Blame is a major impediment to good root cause analysis. We discuss the problems that blame causes in these articles:

• The RaDonda Vaught Case: Moving Past Blame and Punishment
• How Can Blame Cause Accidents?
• Is Blame the Best Root Cause Tool?
• Bias and Blame in Healthcare’s Culture Has to Change

The healthcare environment, with a heavy emphasis on malpractice and liability, is filled with blame. The first article in the list above (the Radonda Vaught Case) is an excellent example of blame getting in the way of good root cause analysis. Not only was RaDonda fired by the hospital after she admitted her mistake and cooperated with the investigation, but she was also criminally prosecuted for her mistake. A doctor talks about how this can complicate future investigations in THIS PODCAST.

Also, the research article states that healthcare professionals, including doctors, are sometimes reluctant to participate in healthcare root cause analysis:

“… because of the distrust generated by possible future consequences. The belief that there is a culture focused on searching “those responsible” – in addition to creating tension in the work environment that may cause interprofessional problems – is one of the main reasons for professionals refusing to participate in incident reporting systems.“

What can be done to reduce blame in the healthcare setting? Read this Success Story from 2011 that describes how blame was reduced in a healthcare patient safety investigation.

Removing blame, as much as possible, from healthcare root cause analysis should be a goal of every hospital.

Lack of Time/Support

The research study at the start of the article stated that the most common difficulties when performing a quality root cause analysis in a healthcare setting are:

“… a lack of time and resources of the work teams. Although none of the studies reviewed refers to how much time is needed to perform an RCA, in the study conducted by McGraw and Drennan, the results of an RCA investigation of pressure ulcers showed that a nurse can take up to 20 hours to complete it.” 

So how much time should be allowed? The article “Resources for Root Cause Analysis – What is Reasonable?” provides some guidance.

That brings us to management support for non-punitive root cause analysis. Leadership in hospitals must take responsibility for effective healthcare root cause analysis. The research study said:

“In only 5 studies (24%) were managers or coordinators included, and in only 1 study were personnel from the service taken into consideration.“

Healthcare leaders need to show support for effective healthcare root cause analysis by scheduling time to be involved in the analysis and review of the analysis results. They also need to ensure there is a tracking system that verifies that the corrective actions are implemented and validates the corrective actions’ effectiveness.

Improper Use of the Root Cause Analysis Tools and Insufficient Training of Analysts

In the research study’s section about the utility of root cause analysis, the researchers said:

“Three studies (15%) showed that the RCA method was not applied properly. François et al. stated that only 23% of the 98 events selected for in-depth analysis covered all the domains defined by the method. Singh [3] pointed out that 65% of the RCAs carried out were not properly completed.” 

As previously mentioned, blame and lack of time/support for root cause analysis were listed as potential causes for healthcare root cause analysis shortcomings. However, I believe three other major factors should be included in the reasons for inadequate healthcare root cause analysis results (ineffective corrective actions). They are:

1. Inadequate root cause analysis tools.
2. Insufficient root cause analysis training.
3. Inadequate review and grading of healthcare root cause analyses before they are accepted for implementation by hospital or facility management.

Let’s look at each of these in greater detail.

Inadequate Healthcare Root Cause Analysis Tools

We described the problems with healthcare root cause analysis tools in the second section of this article. The techniques did not meet the fundamentals of good root cause analysis. Here is a video that describes these fundamentals…

These fundamentals were used to develop an advanced root cause analysis technique – The TapRooT® System.

How does the TapRooT® System work? An industrial example is described at THIS LINK.

Insufficient Root Cause Analysis Training

Once you have an advanced root cause analysis system, you need to train people how to use the system. Who needs training?

• The analysts/facilitators
• Management
• General Employees

How much training do the three groups of people listed above need? I believe that the lives lost due to poor healthcare quality are so significant that people need extensive training.

For analysts and facilitators performing healthcare root cause analysis, I suggest the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. This training will help your investigation teams find the true root causes of patient safety incidents, including the root causes of human performance problems and equipment failures. CLICK HERE for the dates and locations of our public courses held around the world. And if you would like training at your healthcare facility, contact us by CLICKING HERE or calling 865-539-2139.

For training for your management, I would suggest the 1-Day TapRooT® Executive Leadership’s Role in Root Cause Analysis. This training is often completed prior to training your investigators/facilitators so that management can ask the right questions when reviewing an investigation and so that management knows the resources that are needed to perform an investigation.

We also develop custom TapRooT® RCA General Employee Training (usually 4 hours) to ensure that healthcare employees are ready to actively participate in patient safety investigations and that they understand that the investigations are looking for root causes and not looking to place blame.

Inadequate Review and Grading of Healthcare Root Cause Analyses

The video above mentions software for root cause analysis and an essential part of that software is a tool to grade the quality of the investigation. Grading investigations and coaching investigators are keys to continuous improvement of the investigators’ root cause analysis skills.

Senior management should be involved in the review and approval of the root cause analysis. However, we suggest having a peer review committee for review of all serious investigations prior to management review. This review can include the use of the grading tool in the TapRooT® Software. This grading makes coaching investigators/teams a process that is based on well-understood criteria so that the reviews don’t just seem like someone’s opinion.

Questions About Excellent Healthcare Root Cause Analysis?

If you would like to discuss developing your healthcare root cause analysis system, please call Marcus Miller at 865-539-2139 or CLICK HERE to contact him.