Root cause analysis has become a staple at most hospitals, but Dr. Adrienne Green is working to make sure that the lessons learned in these sessions last long after the case is presented in a hospital conference room.
Dr. Adrienne Green
As the chair of the Patient Safety Committee at the University of California, San Francisco (UCSF), Medical Center, Dr. Green wants to take the root cause analysis process to the next step: finding ways to ensure that systems changes implemented after the root cause analysis are sustained over the long term and disseminated throughout the hospital.
“We’re working on figuring out ways to disseminate our learnings, making sure that the changes that need to be spread get spread throughout the hospital, and trying to figure out a way to follow up on the sustainability of our improvements,” said Dr. Green, a hospitalist and the associate chief medical officer at UCSF.
Dr. Green, whose portfolio as associate chief medical officer includes working to improve door to floor time for admitted patients and reducing preventable readmissions, said she is excited about taking root cause analysis in a new direction. “I really enjoy working to bring physicians together with other disciplines within the medical center to fix systems,” she said.
The root cause analysis process has been in place at UCSF for more than 5 years. The analyses are conducted under the auspices of the Patient Safety Committee, whose members, together with local experts and front-line providers involved in an event, review serious events, reportable events, and near misses. The whole process has become more structured and rigorous over time, Dr. Green said.
Part of that evolution has involved generating action items at the close of each root cause analysis and assigning someone who is accountable for implementing each one. Those individuals then report back to the committee 6-8 weeks later, depending on the seriousness of the event. And they keep coming back until the committee is satisfied that the original problem has been addressed.
Over the last year, Dr. Green and her colleagues conducted a review of selected changes to determine if they were maintained over time. They found that about half of the changes that had been implemented through root cause analysis had been sustained, while others “had morphed, and some had just completely fallen by the wayside,” Dr. Green said.
For other hospitalists looking to revamp their root cause analysis process, Dr. Green recommends imposing a firm structure and holding regular meetings. At UCSF, they meet every Wednesday. While this is time consuming, Dr. Green says it’s the best way to keep up with the initial analyses and the follow-up. She also recommends that hospitals adopt structured templates for documenting the root cause analysis and the resulting action items.
Dr. Green cautioned physicians who chair these committees not to try to do it all on their own. She relies heavily on her patient safety coordinator to analyze events and incident reports, help coordinate the initial root cause analysis and follow-up, and “play detective” when needed.
Another element that is critical to a successful root cause analysis process is to build a committee of experts who can ask challenging questions and command the respect of the hospital’s physicians and staff. Then people know that if they’ve promised something to the committee, they need to deliver it, Dr. Green said. “That comes through having the right people at the table.”