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Root Cause AnalysisTraining for HCAI

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Session 1

Welcome and Introductions

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RCA for HCAI Programme

Session SessionTiming

(mins)

1 Introduction 15

2 RCA – Context and Overview 15

3 RCA Process 20

4 RCA Tools 25

Coffee 10

5 Role of the RCA Review Team 25

6 Analysis 55

7 Summary and Evaluation 15

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Session 2

RCA Setting it in context

An introduction to RCA

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RCA – Introduction & Context

What is it?

• A retrospective review of a service user safety incident undertaken

in order to identify what, how, and why it happened

• A process of investigation and analysis is then used to identify

areas for improvement.

• Finally recommendations and sustainable solutions are agreed to

minimise the recurrence of the incident type in the future.

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RCA: Introduction and Context

When should RCA be undertaken for HCAI?

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When should RCA be undertaken for HCAI?

• All MRSA bacteraemia

• Local consideration to CDI cases that may include:

– CDI Deaths

– End stage disease e.g. colectomy

– Outbreaks

– Cluster

• Other infections as per local policy

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Benefits of RCA

for HCAI?

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Benefits of RCA ?Service User• Reduced risk of infection, increased safety and quality of care• Improved service user choice • Increased Public confidence

Providers of Care• Improved quality and safety, focus on risks and contributory factors, ability to target

resources, improved service user pathways, increased service user confidence, shared

learning• Reduced length of stay• Reduced litigation• Improved staff moral

Commissioners of care• Improved assurance, governance, education, communication, clinical practice, shared learning• Improved ability to commission quality care

National • Reduced infection rates, reduced political focus, development of tools and guidance, • increased public confidence

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Session 3

RCA Process

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A Clear Process for HCAIReact- Identify immediate care needs

- Commence treatment and management of bacteraemia

- Identify any obvious problems and take action

Record- Gather data

- Map the patient’s journey

- Arrange RCA review meeting to identify problems, contributory factors and root causes

- Agree action plan

Respond- Deliver action plan

- Monitor action plan delivery and impact

- Identify & act upon organisational themes and trends

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RCA for HCAI: Best Practice Process

• Organisations encouraged to perform gap analysis

against process

• Aiming to embed HCAI prevention into everyday culture

• Guidelines intended as a benchmark for local

interpretation and action to improve on their existing

process rather than replace it

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Process

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Session 4

Root Cause Analysis Data Gathering Tools

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MRSA Data Gathering Tool

Date:

(F) MRSA RCA Data Gathering Tool: InstructionsExamine each of the areas below. Indicate the relevance of each issue to this MRSA by putting a or x in each box. Questions overleaf prompt further information to be collected.

Trust name: Patient identifier:

Service User History Service User Management

Organisational Environment Practice Environment

Prior treatment / interventions

Relevant ( / x):

1Episodes of health

and social care

Relevant ( / x):

2

Contact with MRSA

Relevant ( / x):

4 Transfers

Relevant ( / x):

5

Relevant clinical history

Relevant ( / x):

3

MRSA policy

Relevant ( / x):

11Decolonisation policy

Relevant ( / x):

12 Screening policy

Relevant ( / x):

13

Isolation policy

Relevant ( / x):

14Cleaning and

decontamination policy

Relevant ( / x):

15

Current treatment / illness

Relevant ( / x):

6

Screening and decolonisation

Relevant ( / x):

9

Service user awareness and

behaviourRelevant ( / x):

7

Location and isolation

Relevant ( / x):

10

Invasive devices / interventions

Relevant ( / x):

8

High impact interventions

Relevant ( / x):

16 Hand Hygiene

Relevant ( / x):

17

Cleaning and equipment

decontamination

Relevant ( / x):

18

Uniform and PPE

Relevant ( / x):

19 Care environment

Relevant ( / x):

20

Service User History Service User Management

Organisational Environment Practice Environment

Antibiotic history

Relevant ( / x):

6

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How to use the tool

• RCA Lead completes the data gathering tool prior to the

formal RCA review meeting

• The tool is sent to participants in advance of RCA review

meeting

• RCA Lead maps the data to aid analysis at the review

meeting

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Session 5

Role of the RCA review team

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Purpose of the RCA Review

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Purpose of the RCA Review

• Analyse the data gathered

• Identify problems in the care pathway

• Identify contributory factors

• Identify root cause

• Identify actions to prevent recurrence

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RCA Review

Who should be involved ?

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Who should be involved ?

Core Team • RCA Lead

• Executive lead

• DIPC

• Microbiologist / Infection Control Doctor

• Infection Control Practitioner

• Admin Support

• Risk/Performance Manager

• Matron / Senior Nurse

Care setting representatives• Doctor responsible for management of patient

• Nurse responsible for care of patient

• Others as appropriate

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Develop an action plan

• Provide an ‘expert’ contribution to the validation of the key issues/ emerging findings

• Make recommendations and agree actions that relate to the most fundamental cause(s)

Learning the Lessons• Communicate findings through local staff

bulletins and team meetings• Demonstrate leadership and recognition of the

seriousness of HCAIs to all clinical staff• Ensure outcomes and actions are implemented• Escalate unresolved issues to management

team• Educate staff to ensure new practices are

sustained

Analyse the information

• Contribute to analysis of human and other contributory factors

• Analyse underlying systems and processes through a series of ‘why’ questions

Validate the data

• Review RCA paperwork in advance of meeting

• Contribute to the discussions to validate the information and data

• Challenge assumptions

Roles and ResponsibilitiesOf

The RCA Review Team

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Verifying the data

• RCA Lead checks the findings from the initial data collection exercise

to ensure there are no gaps and all unconfirmed data has been

confirmed

• RCA Lead presents the findings in a logical order to the group

• RCA team identifies the key issues/problems within the findings

• Using a process of brainstorming:

– Capture initial thoughts of the team

– Prioritise in order of importance

• Asking the right question is at the heart of effective RCA process

– This will help to ensure you gather useful information and learn

more

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Identifying Problems

Simple definition

Something happened that should not have happened……

…..or something should have happened, but didn’t.

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Describing your problems

To effectively analyse problems, a specific description of what happened

is required:

Be specific not vague:

• Communication failure = X

• Nurse failed to inform doctor of wound condition = OK

Identify what happened not why:

• Inadequate training on hand hygiene = X

• SHO did not wash or decontaminate his hands = OK

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Analysis of findings

Once the problems have been identified the review team needs to:

• Analyse the key issues/problems

• Drill down to unearth the contributory factors and ultimately the root causes

• Reach agreement on the root cause

• Use tools such as ‘Five Whys’ and the cause and effect diagrams to help

explore the contributory factors of each problem

• Tools are designed to encourage more in-depth analysis at each level of

cause and effect

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‘Five Whys’ Technique

IP&C was not included in the induction training

for new starters

Why?

Nurse failed to undertake MRSA

screening on admission

She was not aware this was a requirement for

emergency admissionsThis was not covered in her orientation to

the MAU

Why?

No Registered Provider wide

approach to ward induction

programmes

Why?

Root Cause

Why?

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Identify Root Cause(s)

What is a Root Cause?

A fundamental contributory factor which, if resolved, will

reduce the likelihood of recurrence of the identified

problem.

• There may be more than one root cause and therefore the RCA team

must identify the contributory factors which have the greatest impact on

each problem.

• Using the ‘Five whys’ technique will help identify the most significant

contributory factors.

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Confirming action plan and follow through

• Chair will lead the discussion on identifying actions to be undertaken

to: – Address the root causes– Highlight the outputs of each action– Outline the timescales for delivery – Identify the responsible owner

• Decide what can be done to prevent the problem happening again

• Explore how the solution will be implemented

• Agree who will be responsible/accountable

• Agree what are the risks of implementing the solution

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Session 6

Analysis

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Analysis

• Who needs to be present at the review meeting ?

• Is there any data missing?

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Participants at the review meeting?

• RCA Lead

• Consultant in charge of patient

• Matron/s

• Ward Managers

• Junior Doctors

• ICN

• Microbiologist

• Pharmacist

• Locality Manager

• District Nurse/s

• PCT Manager

• GP

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Is there any data missing?

• Community screening policy

• A&E record

• Staff training records - PCT

• Staffing levels

• Process for blood culture taking

• Bed management data

– side room use and time to isolation

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Group Activity

Discuss and Identify:

• Problems

• Risks to Other Patients

• Contributory Factors

• Root Causes

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Findings – Pre Hospital

Activity Identified Problems

Long term management of catheterised patients

• No systematic review of care needs or referral for review

• No engagement of continence teams or urology links despite service user requests and ongoing catheter problems

• No detailed plan for long term supra pubic catheter care and type of catheter used

• No MRSA risk assessment undertaken

• MRSA screening was not carried out although service user was high risk – (previous admission to ICU in Spain).

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Findings – Pre Hospital

Activity Identified Problems

Routine change of

supra pubic catheter

• No plan of care for known difficult/traumatic supra

pubic catheter change

• Sensitivities to catheter products not effectively

communicated

• No antibiotic cover to reduce the risk of infection

following traumatic catheterisation. Previous problems

with haematurea.

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Other factors – Pre Hospital

Activity Contributory factors

Documentation • Poor legibility • Lack of chronology and significant gaps in the

records

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Delayed diagnosis of MRSA – Hospital

Activity Problems to be addressed

Screening

Isolation

Decolonisation

Antibiotics

• No MRSA screening on admission despite high risk

• Delay despite diagnosis with MRSA Bacteraemia

•18 hour delay in isolating service user (including multiple bed moves)

• No evidence of cohorting in the intervening period

• No evidence of ICN engagement

• 24 hour delay in commencement of decolonisation

• 24 hour delay in starting IV antibiotics

• Unclear prescriptions on drugs chart

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RCA Review

What are the root causes?

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Session 7

Summary

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RCA for HCAI

Further Reading

• Towards Cleaner Hospitals and Lower Rates of Infection

• 7 Steps to service user Safety

• Anderson, Bjorn & Fagerhaug, et al (2000) Root Cause Analysis Simplified Tools 7 Techniques ASQ Quality Press.

• National Confidential Study of Deaths Following Meticillin-Resistant Staphylococcus aureus Infection. London: Health Protection Agency, November 2007

Useful Websites:

• http://www.hpa.org.uk

• http://www.npsa.nhs.uk

• http://www.dh.gov.uk