As a current or future health care administration leader you may be involved in the determination of organizational mishaps that may be captured by implementing root cause analysis (RCA). As you have examined this week, RCA is a common tool that health care administration leaders might use to help effect organizational change for positive outcomes that foster quality and effective health care delivery in health services organizations.
Review the text chapter and the JAMA article in this week’s resources. Think about the implementation of RCA and reflect on what might be missing from RCA to make more effective and efficient. Think about what techniques might be implemented in health services organizations to implement RCA.
An explanation of the implementation of RCA in an “ideal” organization. Describe what should be done to make RCA as useful as it can be, and explain why. Then, describe how your health services organization, or one with which you are familiar, uses RCA or another process for investigating mishaps. Be specific and provide examples.( Minimum 3 pages)
Ross, T. K. (2014). Health care quality management: Tools and applications. San Francisco, CA: Jossey-Bass.
- Chapter 5, “Root Cause Analysis” (pp. 161–216)
Expert Solution Preview
Root Cause Analysis (RCA) is a crucial tool for healthcare administration leaders to identify and prevent organizational mishaps. However, there are certain aspects of RCA that may be missing, leading to ineffective results. In this answer, an ideal implementation of RCA will be described, along with techniques that can be implemented to make RCA as useful as possible. Additionally, a specific example of how a health services organization uses RCA or another process for investigating mishaps will be provided.
In an “ideal” organization, the implementation of RCA would involve several key steps. First, the RCA team would be properly trained in RCA techniques and methodologies. This includes understanding the process for conducting a thorough investigation, identifying contributing factors to the mishap, and analyzing data to determine the root cause. Second, the RCA team would have access to all relevant information related to the incident. This includes data logs, reports, witness statements, and any other relevant documentation. Third, the RCA team would be given the necessary resources and support to conduct a comprehensive investigation. This includes access to technology, personnel, and time to conduct the investigation without distraction or interruption. Lastly, the RCA team would be given the necessary authority to implement changes based on RCA findings. This includes the ability to make policy changes, modify procedures, or reallocate resources based on the results of the investigation.
To make RCA as useful as possible, there are certain techniques that can be implemented in health services organizations. One technique is to involve a multidisciplinary team in the RCA process. This includes individuals from various departments within the organization, including physicians, nurses, administrators, and quality improvement specialists. This can lead to a more comprehensive investigation and a more well-rounded understanding of the issues contributing to the mishap. Another technique is to ensure transparency and open communication throughout the RCA process. This includes involving front-line staff in the investigation and sharing findings with all stakeholders within the organization. This can lead to buy-in and ownership of the RCA process from all levels within the organization, which can facilitate a quicker and more effective implementation of changes based on RCA findings.
In the health services organization with which I am familiar, RCA is used as a process for investigating mishaps. When a mishap occurs, a multidisciplinary team is formed, and all relevant information is gathered and analyzed. The RCA team then identifies contributing factors and determines the root cause of the issue. A report is then developed, and a plan is put in place to address the issue and prevent it from happening again. For example, if a patient fell in a hospital room, the RCA team might identify factors such as a wet floor, lack of non-skid socks for the patient, and nurse understaffing as contributors to the incident. The RCA team might then implement changes such as making non-skid socks available to patients, increasing the frequency of environmental rounds to check for potential hazards, and increasing nurse staffing during high-demand periods.
In conclusion, the proper implementation of RCA can lead to positive outcomes that foster quality and effective healthcare delivery in health services organizations. Techniques such as involving a multidisciplinary team and ensuring transparency and open communication can make RCA more effective and efficient. The use of RCA in an organization can lead to a more comprehensive investigation of mishaps and can facilitate a quicker and more effective implementation of changes based on RCA findings.