Common Cause Analysis: Focus on Institutional Change

Excerpt

The Children’s Hospital of Philadelphia has created a mechanism for sharing root cause analysis (RCA) findings with senior leaders through annual common cause analysis (CCA). As each RCA is completed, reports are shared with senior leaders and discussed each month at the Patient Safety Advisory Committee meeting. We have found it helpful to summarize these findings each year by organizing the action items into themes. This practice was initiated 2 years ago, and as a result, several high-scoring items have been included on the organizational operating plan for the upcoming fiscal year. Given that endorsement by senior leadership is key to initiating change, these data have proven beneficial to gain this endorsement.

In a year, an average of 25 events, including serious events and near misses, are evaluated. Of those 25 events, about 16 undergo a formal RCA, yielding approximately 10 action items each. These are sorted according to various headings, such as by department and by National Center for Patient Safety Triage Card ™ categories (human factors communication, training, fatigue and scheduling, barriers, rules/policies/procedures, and environment). Once themes are identified, action items are listed under the appropriate theme. Themes are then prioritized by scoring for severity, occurrence, and detectability. Findings presented to senior leaders and other appropriate groups provide objective data for departments. Staff members who conduct RCAs are included in discussions to provide details of the findings and recommendations. They are also included whenever possible in efforts to make changes. This process closes the loop for those conducting the RCA. Once items are added to the organizational operating plan, multiple issues can be addressed through one effort, raising the level of commitment to address the items.