Background
The Clinical Audit Support Centre have gained considerable experience over the years working with healthcare professionals and teams to try and improve patient safety. For example, a number of years ago we worked with the National Patient Safety Agency to conduct an important study examining the quality and impact of significant event audit reports within a Primary Care Trust in Nottinghamshire. We have also helped develop online training for GPs and a series of information leaflets on significant event audit (SEA) for Practice Index website. In addition, we have worked mainly with hospitals to assist them in getting the most from their incident reviews, these being conducted using the established root cause analysis (RCA) approach. Below we provide more detail in relation to RCA and SEA and describe how they can help aid learning from incidents and reduce the likelihood of reoccurrence.
Root Cause Analysis
RCA is a well-established problem solving technique that originated from the manufacturing industry in the early twentieth century. It is not clear who undertook the first RCA, but the Japanese inventor, Sakichi Toyoda (pictured), is often regarded as one of the founding fathers of RCA owing to his pioneering work in relation to the five whys. From the 1960s-80s RCA methods diversified with well known international companies and agencies such as General Electric and National the National Aeronautics and Space Administration (NASA) embracing the approach.
RCA became increasingly mainstream when its’ use was endorsed by the Federal Aviation Administration (FAA) and towards the end of the 1990s the healthcare sector inevitably started to gain interest in the technique. By 1997 The Joint Commission (who accredit healthcare providers in the USA) were advocating RCA and by 2004 the National Patient Safety Agency had created a comprehensive toolkit of resources and were offering training to healthcare professionals across England. RCA is now an established investigatory approach used throughout the NHS but predominantly in hospitals to help establish the root and underlying causes of why an adverse incident has occurred.
There are many different definitions for RCA, but the NPSA’s stands the test of time, describing root cause analysis as ‘a systematic investigation technique that looks beyond those individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened’. The Wikipedia definition for RCA is also worth considering, that being ‘RCA is not a single, sharply-defined methodology; there are many different tools, processes and RCA philosophies in existence’.
CASC can help your team get the most out of root cause analysis. We offer one-day in-house accredited training courses in RCA that can be adapted to meet the needs of learners – click here for details. We can also help review your patient safety and RCA processes to ensure that they are fit-for-purpose. We have also created a range of new materials and resources to aid those conducting RCA and you can find these within the patient safety section of this website.
Significant Event Audit
SEA is a risk management technique that has become increasingly popular in the NHS and wider healthcare circles. The origins of SEA are not entirely clear, but many suggest that it evolved from the Critical Incident Technique adopted by JF Flanagan and used by the United States Air Force in the 1940 and 1950s. There is some evidence that Pittsburgh Dental School adopted the technique after the war but with respect to the NHS a debt of gratitude should be paid to Professor Mike Pringle (pictured) who published his ‘Occasional Paper on Significant Event Auditing’ via the Royal College of General Practitioners in 1995.
It is fair to say that the work of Pringle moved SEA from an approach on the margins of general practice to the middle of the page. SEA was included in the Quality and Outcomes Framework in 2004 with all practices expected to undertake a minimum of six significant event audit reviews in the past three years. By 2008 the NPSA were extolling the virtues of SEA via a comprehensive guide and since 2012 all doctors have been expected to reflect on significant events and share this information with their appraisers as part of the revalidation process. The Care Quality Commission expect significant event audit to be firmly embedded in general practice and they routinely ask to see evidence as part of their inspections. Given the extensive amount of time spent on conducting RCA it is also noticeable that teams are turning to SEA as an alternative and quicker process to review their incidents.
Definitions of SEA are largely consistent and we would advise that Professor Pringle offers a robust interpretation describing SEA as: ‘a process in which individual episodes (when there has been a significant occurrence either beneficial or deleterious) are analysed in a systematic and detailed way to ascertain what can be learnt about the overall quality of care, and to indicate changes that might lead to future improvements’. This definition also features in the NPSA guide. In a nutshell, the main difference between SEA and RCA is that whereas RCA is typically a more formal and detailed investigatory process often carried out by external staff, SEA is a more rapid internal team-based review process.
CASC can help your team get the most out of significant event audit. We offer half-day and one-day accredited training in SEA – click here for details. We can also work with general practice teams to review how you manage patient safety incidents to ensure that the process is fit-for-purpose. We have extensively reviewed CQC data and can provide advice on how to best prepare for CQC inspections. In addition, Tracy Ruthven (CASC Co-Director) is a current Freedom to Speak Up Guardian and she is happy to provide advice in relation to this recent initiative. Click here to find out more about Freedom to Speak Up Guardians. We have also created a range of new materials and resources to aid those conducting SEA and you can find these within the patient safety section of this website.