The beauty of quality improvement is that the teams get to meet regularly to review their progress against the process indicators they are tracking. That said, this is not always all happy and cordial. Sometimes it gets to a point of confrontation especially when the teams are just beginning their improvement journey.
A few weeks back I had to sit through a quality improvement meeting with a team in one hospital just beginning their Improvement work. A documentation audit review indicated that there was a steady decline in the monitoring of vital signs for patients therefore poor clinical outcomes. Upon random review of one file, the patient in question had been discharged without a recheck of their vital signs and the last reading had shown extremely elevated blood pressure reading. Of course, at this point, everyone in the meeting understood the repercussions of the incident based on the medical history of the patient. Naturally what followed was everyone trying to pass the blame around from the doctor who discharged the patient, the nurses on duty, the leadership and therefore provided a very good forum to perform a root cause analysis to identify the real cause.
Getting to the heart of a problem – locating the roots – is sometimes a difficult task especially in a health system with more than one challenge. In quality improvement, we advocate for it nevertheless because every time we solve the problem and not the cause of it, it happens again, and a vicious cycle is created.
In this case, it was easy to use the five why’s technique to get to the real cause of the problem at hand which was poor monitoring of vital signs leading to poor clinical outcomes. i.e.:
Patient discharged with elevated blood pressure from last reading [why]
Vital signs monitoring not done that day [why]
Lack of blood pressure machine and thermometer in the ward [why]
Nurse in charge refused to supply the ward with more vital signs monitoring equipment[why]
The equipment has been disappearing from the ward within a month of supplying from the store [why]
Handing over of equipment is not consistent in the ward especially over the weekend, [why]
root cause analysis- RCA
There is no formal process in place, therefore, no accountability. [why?]
If we were to solve the problem and not the cause of it, the traditional way would have been to punish the doctor and the nurses on duty when the incident occurred. Contrary to the traditional way, the team ended up developing an SOP on handing over and an implementation schedule that would ensure the problem never occurred again.
Whether you conduct a root cause analysis using a method that involves asking a series of “why” questions or you rely on a method that uses tree charts or cause and effect diagrams is not important. What matters most is that you have a reliable process and use it to analyse information so you can identify both the cause of problems and solutions to those problems at the most fundamental level.
I am very sure that when you look around our health systems, the challenges identified and how the solutions are derived you would agree that we are constantly attempting to solve the problem and not the cause and that’s why the health indicators being tracked have little if no improvement at all. From the recruitment of more health workers to one-off training and purchase of numerous equipment to handle quality issues instead of addressing at the point of care.
Bottom line is, the whole quality improvement team should participate in this exercise if the real cause is to be defined for corrective action. The key is to avoid assumptions and encourage the team to keep drilling down to the real root cause. If you try to ﬁx the problem too quickly, you may be dealing with the symptoms, not the problem, so use ﬁve whys to ensure that you are addressing the cause of the problem. Remember, if you don’t ask the right questions, you won’t get the right answers.
Root cause analysis (RCA) helps quality improvement teams retrospectively study events where patient harm or undesired outcomes occurred to identify and address the root causes. By understanding the root cause of an event, we can improve patient safety by preventing future harm. A good root cause analysis allows for the design and implementation of a solution that addresses the failure at its source.
On a lighter note, root cause analysis can be used in any aspect of our lives and not only the clinical one. Go ahead and try it.
In my experience, often the causes of the problems are process failures and not people failure.