The RCA Gone Wrong

I’ve written before about Root Cause Analysis, those things hospitals do when there’s a serious safety event. A good RCA will include a description of the event, a timeline of everything that happened leading up to the event, all of the people involved, an investigative team, a report out that focuses on process, not people, and asks ‘why’ until you get to the root of the issue, and plans for corrective action. 

They’re good things to do. When done well, the participants leave with a better understanding of where the process broke down and what steps they can take to improve it. Staff who had been struggling with guilt or regret often feel much better afterwards because they had a chance to see how other factors contributed to the event. Silos are broken down as a result of people from many departments coming together and examining how their individual efforts affected the outcome. 

Staff feel supported by leadership and empowered to make changes when RCAs are done well.

But what if they’re not?

I participated in an RCA a few years ago that ended up doing more harm than good because of a poor facilitator and a misdirected leader. 

It was a terribly sad case; a patient came in with a seemingly minor issue requiring some routine surgery but suffered an arrest in the operating room and didn’t survive. In the days that followed, there was a lot of finger pointing. Rumors were swirling throughout the whole hospital. The staff who were involved were feeling terrible about the outcome and unsupported by their leader. It was a very messy situation. 

The Vice President of Patient Safety and Risk scheduled the RCA as he always did and included everyone who had been involved but this time, something was different; the president wanted to attend. He hadn’t had any involvement in the case but wanted to see and hear what was discussed at the RCA. If this had been a president who was visible, approachable, and often involved in the day-to-day activities at the hospital, this might not have been a bad thing. But this president was none of those things. Having him there inhibited the participants and made them feel even more like they were under attack. 

When we started talking about how things broke down and began to ask those “why” questions, the president chimed in and asked, “Why, if that was your responsibility, did you not do it?” The VP tried to jump in and bring the focus back to the process, not the person, but the president wouldn’t let it go. It was easy to scapegoat this particular nurse, but if you took a step back, you could see there was a bigger issue here. Many things were going on at that moment and we, as the investigators, have to see it from the perspective of what was happening as it was happening, not from the benefit of hindsight. 

The RCA continued in much the same way, with the president asking very pointed questions to the people in the room about their personal responsibility for the outcome instead of looking at  the many different ways the process failed. As much as the VP tried to keep things on track, he simply couldn’t get control of the meeting. It was a disaster. We left the room feeling worse than we did when we entered with no real resolution or plan for corrective action. 

I can’t speak for the president but I suspect he left feeling very satisfied that he got to what he thought was the issue: a bad nurse. I can’t begin to describe what a huge step backwards this RCA was, not only for staff morale but for patient safety. When staff feels that they will be blamed for every mistake and there is no tolerance for error, they don’t perform better, they perform far worse. 

A culture of safety is so much more than zero harm. It’s staff who are empowered to speak up when they see something wrong. It’s channels that make it easy to report an issue or a near-miss, along with a feedback loop so employees know that action is being taken. It’s processes in place with several steps along the way to catch mistakes before they reach a patient. It’s leaders who don’t set out to find a scapegoat when things do go wrong. It’s providing safe spaces for staff to talk through events once they’ve occurred. It’s staff working across their departments, together, to keep patients safe. It’s everyone working together, focused on patient safety throughout the continuum of care. 

I’ve participated in many more RCAs since this one and am happy to say they go well much more often than they go wrong. But when they go wrong, it takes a very long time to recover.

Author: Kate Kalthoff

It's simple: leave people, places, and things better than I found them. For more than 20 years, Katherine Kalthoff has been working to improve the way healthcare organizations connect with the people they serve. She began her career at Gift of Hope, the organ procurement organization for Illinois, approaching families and securing their consent to donate a loved one’s organs for transplant. Through compassionate, empathetic listening, Kate led the Family Services team to one of the highest consent rates in the country. From there, Kate went to Advocate Health Care, Illinois’s largest healthcare system, as a Physician Relations and Business Development Manager, improving physician satisfaction and strengthening the relationships of both the employed and independent physicians with the system as a whole. Just prior to joining Northwest Community Healthcare as the Patient Experience Officer, Kate was the first Manager of Patient Experience at DuPage Medical Group where she built a platform of organization-wide service excellence through her inspiring brand of education, training, and one-on-one coaching. A much sought-after speaker and trainer, Kate has a very simple approach to her work: leave people, places and things better than you found them.

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