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RCAs can boost quality without taxing staff

Quality Improvement Monitor, January 11, 2008

Safety systems in high-risk industries such as the National Aeronautics and Space Administration may be stellar, but they really can't be applied to the healthcare setting, can they? And root cause analysis (RCA) is too complex, too expensive, and too time-consuming, right?

"That's absolute balderdash," says James Bagian, MD, PE. "It's just baloney." Bagian should know. A former astronaut, he helped investigate the causes of both the Challenger and Columbia shuttle disasters. He is now the chief patient safety officer for the Veterans Health Administration (VHA) and chief patient safety officer and director of the VA National Center for Patient Safety.

It requires only one-quarter of a full-time equivalent (FTE) employee per year to do 12 effective RCAs annually, says Bagian, the chief architect of the VHA's much-vaunted RCA process. "So when facilities say, 'We just don't have the manpower or the staffing,' I say, 'That's ridiculous,' " he says. "No one manages their FTE that closely. People spend more time talking about who's going to win 'Dancing with the Stars' or who's going to win the Super Bowl."

The VHA, he says, began looking at RCAs in earnest in 1999, years before The Joint Commission (formerly JCAHO) began requiring them under Standard PI.2.30. It embarked on its RCA process following a culture of safety survey the organization conducted in 1998. The survey revealed that humiliation-just as much as, if not more as, malpractice suits-caused people not to probe errors or near misses. For that reason, the VHA focused on prevention rather than punishment when it created its process for root cause analysis-a term Bagian calls a misnomer. "First, there is seldom one root cause," he says. "There are numerous roots or contributing factors."

Second, the term doesn't stress the need for an action plan. "If all you do is figure out the causes, and that's where you stop, nothing is accomplished," Bagian says. "And if you stop at analysis, which many places seem to do, and don't have action plans that are implemented and documented, what's the point?"

Access the full story in the January issue of Quality Improvement Report; access is free for subscribers, nonsubscribers can purchase a copy of the story for $10.

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