What is an RCA investigation?
Root cause analysis (RCA) was developed for the health services to promote a systematic approach to the investigation of serious incidents. In the past, many investigations did little more than identify the mistakes that happened in the process of care.
If undertaken well, an RCA investigation will find out what happened, get beyond ‘the obvious’ to the bottom of why the incident happened. A good RCA investigation will identify any underlying system and process issues that may have caused or contributed to the incident.
NHS trusts have adopted the RCA process to investigate serious incidents that result in moderate, severe harm or death.
Trusts have developed different approaches on who should carry out an investigation. Our feedback shows that in most trusts, managers and senior clinic RCA investigational staff are the most likely people to undertake the investigation.
Investment, training and support
One common problem that we see is that those who are expected to carry out RCA investigations don’t receive training or support by the trust. This can result in investigations that lack rigour and focus and, therefore, don’t get to the real causes of what went wrong. Poor RCA investigations like this leave the trust open to increased criticism, complaints and claims which in turn can lead to low public confidence.
The patient safety incident investigations training course from Verita provides participants with the human error theory and the investigative tools and techniques needed to carry out a thorough and proportionate RCA investigation. These tools help participants to learn how to see beyond the obvious and to drill down to diagnose the real underlying causes of the incident. Feedback from course participants consistently shows improved confidence and ability in carrying out investigations into serious incidents.
Apart from ensuring that investigators receive training and regular updates, trusts can provide further support by setting up a buddy system. Using this model, experienced investigators act as a buddy for inexperienced investigators to provide supervision, advice and a buffer so that any problems or issues that come up during the investigation can be shared and discussed. The buddy can also undertake a role in relation to quality assuring the investigation report. Feedback from trusts that have developed this model say that staff are more likely to agree to undertake investigations. This is because they feel better supported and more confident. Furthermore, trusts reported that the quality of RCA investigations had improved.
Importance of RCA investigations in NHS trusts
A report on ‘Learning, candour and accountability’ by the Care Quality Commission (CQC) reviewed the way NHS trusts review and investigate the deaths of patients in England. The report analyses processes and systems in English NHS trusts (acute, mental health and community trusts) and highlights the fundamentals that need to be in place to learn from problems in care before the death of a patient. The CQC note that people with a mental health problem or learning disability are likely to experience a much earlier death than the general population, so the review focuses closely on how trusts investigate the deaths of people in these population groups.
The CQC concludes that many carers and families do not experience the NHS as being open and transparent and that opportunities are missed to learn across the system from deaths that may have been prevented. The report states that there are “system-wide” problems with current approaches for engaging loved ones including a level of “acceptance and sense of inevitability” when people with a learning disability or mental illness die early.
Families described a poor experience of investigations and told the CQC they were not consistently treated with respect, sensitivity and honesty. The report outlines six recommendations to improve investigating and learning from serious incidents. The emphasis is on engaging families and carers and recommendations include developing a new single framework on learning from death and advising when an independent investigation may be appropriate.
Conclusion
Trusts can improve RCA investigations by ensuring that investigators receive proper training (and regular updates) so they understand the theory, RCA tools and techniques to be able to carry out a proportionate investigation.
Investing in systems to support, and provide advice for investigators can also promote increased confidence and a willingness to carry out serious incident investigations.
If you would like to learn more about RCA Investigation Training (now called the Patient Safety Incident Investigation Training course), then please contact Chris Brougham on 07872 130637 or [email protected].
