Bringing policy makers, healthcare leaders, innovators and scientists together to discuss the safety of healthcare sounds like the ideal action to advance safety in healthcare. In essence, it is and was.
Yet, I found myself thinking about why we haven’t moved faster and achieved higher standards of safety of quality in our healthcare setting. It is easy to give reasons. Complexity, acuity, workforce shortages, lack of resources are common statements.
I have a different thought to offer: How much does our unconscious bias influence actions? Let me give you an example. While touring a hospital in the UK, I noticed two different colored non-skid slippers socks at the patient’s bedside. Curious, I asked why they had two different stockings with two different colors. It did not make sense to me.
Surprised I was asking that question; they looked at me and said, because we do not want what is on the floors in the patient’s bed. One pair/one color is for walking and ambulation, the other is for when they are in the bed. We accept that people walk in their slippers in the U.S. and then get into bed, bringing with them whatever is on the floors where they’ve walked.
Let’s look at bias in another way. I recently spoke with a nursing leader who expressed frustration over her quality metrics. She felt that if people would just follow the policies, they would have a better performance.
When I asked which metrics frustrated her the most, it was falls and pressure injuries. As we talked through her root-cause analysis process, it became clear that they were struggling with getting beyond the blaming of individual accountability to systems failures and barriers that create human error.
In examining bias about root cause analysis, here is what we know: Leaders “know” they need to be done; but…
1. Most organizations lack a total systems approach to safety.
2. Debriefs are done on a superficial level.
3. There is awareness of the importance; but the process of discovery is still on finding the individuals who might have breached policy, instead of understanding where there are failures in the system.
4. We don’t see or hear the stories that are rich in learning when we do not examine deep causations.
5. Stopping and examining near misses and events is not part of the daily work; there is no protected time to learn or reflect.
6. There is still blame and shame approach when events occur and the root cause analysis is done only when something “really bad” happens.
A systematic approach to learning and advancing quality has to be done. Toolkits are now available for to help guide organizations toward.
Establishing methodology and processes to utilize root cause analysis for quality improvement also takes discipline. One of the first steps is to challenge your own beliefs about safety and quality failures. Do you believe it is bad people, or bad systems and processes? Or do you see it a little of both? What actions do you take from your reviews and analyses?
RCA2 (Root cause analysis squared — spelled out it’s at http://www.npsf.org/?page=RCA2) is a way to examine your actions, learn more about how to guide your organization and most importantly advance safety and quality for those we serve.
Martie Moore, RN, MAOM, CPHQ, is the chief nursing officer at Medline Industries Inc. and a corporate advisory council member for the National Pressure Ulcer Advisory Panel.
