Root Cause Analysis Model

Quality Improvement

Timothy Cox

Notre Dame of Maryland University

Quality Improvement Quality improvement (QI) consists of systematic and continuous actions in order to achieve a measurable improvement in quality of service and health status of targeted patient populations. Quality improvement is a critical tool that allows health care professionals to solve complex problems and provide patients with the best possible care available. Health care facilities are constantly trying to find ways to improve systems currently in place as well as analyze current problems to remove the root cause of undesired events; the facility I am at currently is no different. My facility currently implements the Root Cause Analysis model to

Root cause analysis is a process to identify the basic causal factors that result in undesired outcomes of patient centered care. The Joint Commission defines sentinel events as a patient safety event that is not primarily related to the natural course of the patient’s illness or underlying condition that results in death, permanent harm, or severe temporary harm (jcrinc). The root cause is the foundation from which these sentinel events occur. The importance of the RCA is that is does not invoke blame on health care personnel but instead examines events that lead to the undesired outcome. The analysis focuses on a positive preventive approach to system and process changes following a sentinel event. The purpose of the RCA is to figure out what happened, why it happened, and determine what changes need to be made to prevent further undesirable situations. This method is utilized at our facility based on the guidelines set by the Joint Commision to investigate harmful events. The Joint Commision lays out a seven step process to analyse the root cause. The requirements are as follows, identify the event to be investigated and gather preliminary information, select a team facilitator and team members, describe what happened, identify contributing factors, identify the root causes, design and implement changes to eliminate the root causes, and measure the

The people involved are also known as stakeholders. Stakeholders are individuals or groups with the responsibility for completing a project and influencing the overall design, and those who are most impacted by success or failure of the system implementation (Mcgonigle). This process all starts with the performance improvement department at our facility. They are incharge of selecting events for the Performance Improvement Projects (PIP) involved in the RCA. The performance improvement department is also in charge of gathering information about the incident including the incident report or any other documentation surrounding the event. This initial investigation can also include interviews of the staff involved as well as the patient and the any family members that were present. This information includes the data that was collected and is useful in deciding how the performance improvement department selects candidates to serve as members on the team. It is important to involve facility leaders to prioritize the project and proceed with the RCA. My facilities justification for examining why patients continue to develop pressure ulcers was due to the fact that the performance improvement department acted on reports received from the orthopedic department. After the initial investigation period the team they assembled included the nurse manager on our floor, several of the senior clinical nurses, as well