MHA Keystone Center Leadership Corner: July 2017

Posted on July 13, 2017

The Leadership Corner features monthly updates from the Michigan Health & Hospital Association (MHA) leadership team. The updates will provide new insights to patient safety and quality as well as information obtained from healthcare workshops and conferences across the country.

Brittany BroganBrittany Bogan, MHSA, CPPS, Vice President, Patient Safety & Quality, MHA Keystone Center shares how leaders can ensure their RCA efforts are valuable in this month's edition.

In late May, the MHA Keystone Center Patient Safety Organization (PSO) launched a series of comprehensive Root Cause Analysis and Action (RCA²) trainings, which were based on the National Patient Safety Foundation’s 2015 report, RCA²: Improving Root Cause Analyses and Actions to Prevent Harm.

Root cause analysis (RCA) in healthcare is an essential process to reduce and eliminate patient and staff harm, and its success is dependent upon the rigor and quality of the process implemented within each organization. Experience has shown that the traditional RCA process has had variable success in improving patient care and safety. Data collected through the PSO also revealed ample opportunity to enhance the process used by MHA-member hospitals, specifically related to the development, implementation and measurement of action plans resulting from the RCA.

The RCA² method was developed to provide guidance on how to implement standardized processes that produce effective and sustainable actions that will prevent future patient and staff harm. The purpose of RCA² is to find out what happened, why it happened, and outline what will be done to prevent it from happening in the future.

Active participation and engagement of leadership is required for the enhanced process to effectively and sustainably reduce harm, so the MHA Keystone Center is busy educating hospital leaders about the RCA² trainings and encouraging them to support the implementation of action plans following a RCA within the hospital.

The following recommendations were shared with the MHA Board of Trustees at their June meeting, which encouraged the hospital CEO, or another appropriate member of top management, to support the RCA² process via the following actions:

  • Review the RCA executive summary
  • Approve staff from their organization to attend one of the upcoming RCA² training sessions
  • Develop a plan for visible and tangible involvement of both hospital leadership and the board in the RCA² process, including a review of each RCA² action plan and written approval or disapproval of each action recommended by the RCA team

In short, if the actions resulting from an RCA² are not implemented and measured to demonstrate their success in preventing or reducing the risk of patient harm, the entire RCA activity can be a waste of time and resources. Leadership involvement demonstrates this as a priority issue for an organization and the MHA Keystone Center PSO will continue to engage and educate staff at all levels of the hospital.

Our team is available to assist each member organization in enhancing their current RCA process and looks forward to seeing many of you at the upcoming trainings this fall. For questions (or comments) in the meantime, please contact me.

Have a wonderful July!

This article was featured in the new MHA Keystone Center Newsletter. To subscribe, please contact Ashley Sandborn, MHA Keystone Center communications specialist.

Tags: MHA Keystone Center, Patient Safety and Quality, PSO, RCA2

Posted in: Patient Safety & Quality

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