5 Key Takeaways from QUASR RCA Survey Findings

Hak Yek Tan

Why does this survey matter to you?

Incident investigation and RCA is a subject of deep interest and serious concern to all of us. Have you come upon similar adverse events recurring in your organization after RCA has been conducted? How many formal action plans have your team initiated and implemented after RCA reviews? Are the control measures taken effective in improving patient safety?

These are the questions we ask in the QUASR Guide to Improve Effectiveness of RCA. The eBook discusses the challenges of RCA and reasons for the general lack of effectiveness of RCA in healthcare. It also outlines key approaches and considerations for RCA review in order to bring about sustained improvements

QUASR RCA Survey is a follow-up on the eBook. We want to hear your feedback and the plans you have to enhance RCA processes in your organization. A survey was conducted via email and at APHM 2022 Exhibit to gather feedback. While the sample size is relatively small (46 respondents), we believe the findings nonetheless provide valuable and actionable insights for sharing with other healthcare organisations.

Let us start a conversation on this topic that matters to you.


Profile of Respondents

Our survey targets investigation team members in hospitals. This includes senior management (Hospital Directors/Medical Directors), Quality Directors/QA/Risk Managers, CNOs/Nurse Managers/Nurses, and subject matter experts (clinicians).

 

 

Respondent Profiles Distribution

Prevailing Set of Common Challenges

Respondents were asked to pick the top 3 challenges from a list of 6 common challenges when conducting incident investigation and RCA. There is an “Others” option to gather additional issues of concern. One such feedback is that RCA reviews often provide sub-optimal root causes, rightly pinpointing the crux of the matter. We can’t just look at the obvious direct causes, but should conduct deeper analysis and take a system-wide approach to identify the hidden root causes.

 

The survey findings provide anecdotal evidence on a prevailing set of common challenges hospitals are facing.  The top 3 challenges are resource constraint (58.7%), difficulties in coordination (54.3%) and lacking follow-up actions after RCA reviews (50.0%). The other challenges, namely lacking the necessary skill sets, staff attitude due to defensive culture and incomplete incident records due to manual process are also widely cited.

Challenges in Incident Investigation and RCA latest

How to Enhance the Effectiveness of RCA?

The next survey question on how hospitals plan to enhance the effectiveness of incident investigation and RCA provides useful and actionable insights. A majority (more than 50%) of the respondents’ rate conducting trainings, implementing an online incident reporting system, and taking a risk-based approach as their preferred plans. Training (71.7%) is by far the respondents’ most preferred plan to enhance RCA review.

Other action plans are also widely cited, namely promoting a safety culture, setting clear and measurable targets, and involving senior management in RCA review. One respondent recommends sharing lessons learned, which is indeed a great way to enhance the value of incident reporting.

 

Improve Effectiveness of Incident Investigation and RCA latest
Majority is Ready for Digitalization

The third and last question is on readiness for digitalisation. A majority (73.9%) say their Quality Management Department is ready for process automation and digitalisation.

Process Automation and Digitalization
5 Key Takeaways
  • ● Healthcare sector is facing many challenges in incident investigation and RCA. These challenges are negatively impacting the effectiveness of RCA and prevention of adverse events from recurring. But there are several measures you can take.

    ● Do not assume your staff have the required skills. Conduct regular trainings on incident reporting, investigation, and RCA for your QA, nursing and HR

  • ● Implementing an online incident reporting system can help address several challenges identified in the survey. Digitalize your processes to lessen staff workload and increase collective participation.

  • ● Adopting a risk-based approach on investigation and RCA. This will necessitate that you conduct risk assessment as part of patient safety management.

    ● Promoting just culture, setting clear targets and getting senior management involvement are the other measures you can take.

We welcome your comments. Please email to hak@healthgrc.com.

Your feedback will help us better understand the issues you face and solutions you need

Why should you keep your process simple

Abishek Goda
simple incident process

“Everything should be made as simple as possible, but not simpler.” – A quote often attributed to Nobel winning Physicist Albert Einstein.

Incident Management process is often quite simple. The process provides a lot of information beyond incidents themselves and are essential inputs for overall clinical risk management as well. In many cases, the knowledge that the incident management process is a first step to overall risk management is sufficient to drive us into analysis paralysis mode. Risk management is a very complex topic and has far too many factors in its implementation. We, at QUASR, have insights into clinical risk management and we will eventually integrate QUASR to provide this option for our clients. In this post, we want to address some of the common complications in implementing an incident management system and our solutions.

QUASR follows an industry-standard workflow for incident management. We implement a simple workflow and we are pretty proud of that fact. We believe we have achieved the simplest possible standard workflow that also captures the essence of incident management itself. However, during enterprise implementations, clients usually need quite a bit of convincing as to why this simple workflow is usually a good place for their needs. From our experience, this happens in two cases: when the clients have a legacy system that they have used for a while and are looking to keep the same process. Or they are looking to map their existing manual flow as-is into the new system. Both these approaches, frankly, are inefficient. Let us explain.

Legacy System Hangover

Systems that were built at least a decade back qualify as legacy systems. Any reasonably newer system might not have the issues that we are going to discuss here. For newer systems, the IT team was likely asked to implement their manual process as is! In software circles, there is an inside joke – “some unexplained bugs are actually features.”.

On a more serious note, systems that were implemented a long time back don’t fully take advantage of all the technological developments of recent times. Some of their design decisions could have been technology driven rather than user driven simply because it would be prohibitively difficult to implement differently.

A newer system built on more recent technologies doesn’t suffer from the same limitations. And hence it is possible to achieve more elegant solutions or workflows than wasn’t possible in a legacy system. That said, if we carried forward the legacy system as is, we might not fully utilize all the enhancements that technology offers us.

Mapping Manual Process to Digital Process

Since many of our customers are implementing their first digital system for incident management, this is the typical set of issues we face while onboarding and customizations. Many things we do manually, do not scale well to digital systems as such. And we all have seen examples of this: have you ever tried to collect all people interested in paying for a gift to a colleague? We send out an excel sheet and each person returns a sheet of their own and we merge them manually?

That’s exactly what we’d do before emails. We’d just go person to person, find out if they’d contribute and write it down in a piece of paper. But we all do know how inefficient that is, right? If we have to do the same thing today, we should probably set up a google form that each of the participant fills out and you get an excel sheet at the end of it. Same data is collected but far less work needs to be done by the person trying to collect it. The second option is a more digital native way of solving that problem. Incident management, incidentally, is full of such problems.

A typical example we often get as a customization request is to include additional workflow steps: include HoD as part of the workflow. Yes, we understand why you’d want to do that. But in many cases and as many of our customers agree too, this step is an FYI for the person involved. In a manual system, the HoD had no way of knowing what was happening unless you intentionally ran things by them. But digital systems aren’t really like that. Online systems are even lesser so. You’d just need to notify them in these cases.

In QUASR, we solve this problem by automatically having HoDs in the loop for all incidents in their department. You don’t need to do this additionally. However, we do not notify them every single time. EMail based notifications have become so common that we mindlessly mark things to read or archive them even without reading them. And we do not want to add to the inbox clutter either. So the HoDs just have to login periodically and they’d be updated on all the active incidents in their department. But unless we explain this, most of the users don’t see the solution. They are wondering how to implement an additional step in the workflow because that’s what they do in the manual flow.

Another example is typically around data collection fields. Many clients request adding quite a few descriptive fields whereas these aren’t very useful for systematic analysis. Descriptive data necessitates quality managers or investigators to spend time reading and understanding much information. But there is another downside: lack of sufficient information. Some people can describe an incident in vivid detail while others tend to write very little. Situations like these can be avoided by collecting quantifiable, standardized data instead. This, too, is an artifact of using paper based forms.

In paper based forms, it is impractical to collect incident type specific information for every incident type we want to track. So we end up with a few generic descriptive boxes for the users to fill up. However, adopting the same to a digital system does not allow you to utilize the full power of a digitalized solution.

Adopt Digitally Native Solutions

We just saw a few reasons why users typically have difficult-to-use, complex workflows in a digital system. But it’s not entirely their fault. As service providers, our first mantra is “Customer is always right!”. Blindly following the mantra, however, does very little to help the customer. While the customers know what they want, it is our duty to explain and clarify how best to provide what they want. Users tend to get carried away at the flexibility and try to plan for a future well ahead. It is worth remembering that technology evolves faster than our processes. So it is not very useful to plan far ahead into the future but plan for medium to short term only.

Enhancing software solutions are often quite simple and needn’t be as expensive either. Hence it is better to implement enhancements when the need arises rather than implement them all at once. Besides, having a digital native solution allows us to adapt to a digitalized workflow better – especially moving from a legacy or a paper-based system. Once we have acclimatized to a digitalized solution, we are better suited to decide how we need to enhance our systems in the future.

7 Essential Patient Safety Tools

Hak Yek Tan

Going Back to Basics

Simple and easy to use tools can bring surprising insights and amazing results. Most healthcare professionals especially safety and quality officers are familiar with and use them during their day-to-day work. Yes, we are talking about essential patient safety tools and techniques that ensure the delivery of safe and reliable care. These tools are the foundation of your hospital’s patient safety practices.

This article looks at 7 essential patient safety tools that are commonly used by hospitals and other healthcare settings. Most of the tools are simple and easy to use practical hands-on techniques. These essential tools are effective and provide a structured and systematic approach to improving patient safety. From fostering a culture of safety and teamwork, understanding the problems and bottlenecks, identifying root causes and areas for improvement, to proactively predicting and preventing failures, the toolkit can bring about sustained improvements. It is your companion in patient safety.

Listed below are 7 essential patient safety tools for your toolbox. You will find a short description for each of the tools, when to use them, how they work and in what way they help to improve patient safety. A general guide on tool selection for specific scenarios is provided for quick reference.

 

7 Essential Patient Safety Tools and Techniques

1. Safety Huddles

A short meeting involving multidisciplinary care team members at the start of a workday or shift to focus on care coordination identify safety issues and flag concerns. It is an effective and efficient way for healthcare teams to review performance, share information and enhance team communication. In the process, it helps to build a culture of safety and teamwork.

2. SBAR (Situation-Background-Assessment-Recommendation)

This is an easy-to-use, structured form of communication that enables information to be transferred accurately between individuals. It helps you to formulate your thinking and convey information clearly and by doing so prevent miscommunication. SBAR is particularly effective in communication across different disciplines and between different levels of staff.

 

3. 5 Whys

This is a simple yet effective tool used to identify the root cause of a problem by repeatedly asking the question “why” 5 times. It helps us to truly understand a problem and get to the root cause. No statistical data required. This tool allows you to focus your resources on the right area, solve the true cause of a problem, and not just its symptoms.

4. Action Hierarchy

Action Hierarchy tools help to determine the strengths of the action by levels or categories. The outcome of an investigation and root cause analysis is often a set of recommended actions (hence RCA2).  This tool will assist the team to identify corrective/preventive actions that will give the biggest impact and greatest results.

5. Cause and Effect Diagram

Also known as Ishikawa Diagram or Fishbone Diagram, this tool helps your team to explore the many causes contributing to a certain effect and graphically displays the relationship of the causes to the effect or outcome. It is a commonly used tool to help identify areas for improvement. Causes are typically grouped under 5 categories, namely People, Methods, Materials, Equipment, and Environment.

6. Process map

A process map or flowchart is a graphical representation of the sequence of steps and how things get done in a process. It helps your team to visualize and have a clear understanding of current processes – an important first step to help identify problems, inefficiencies, and areas for improvement. Common symbols are used so that the flowchart is easily understood by everyone.

7. FMEA

FMEA is a tool for conducting a systematic analysis of a process or product to identify and prevent the problems before they occur. It prompts your team to proactively review and evaluate what could go wrong (failure mode), why failures happen (failure causes), and the consequence of failure (failure effect).  Improvement plans can then be carried out to prevent those failures. The focus of FMEA is to proactively identify potential risks and their impact, prevent failures and make the system more resilient.

General Guide on Tool Selection

Look for opportunities for safety improvement or launch new safety improvement programs in your hospital. Set your patient safety goals and objectives. Use the following as a general guide to select the appropriate tools.

Source: Developing a safety culture, building teamwork and enhancing communication – Safety Huddles, SBAR