The root cause is “the evil at the bottom” that sets in motion the entire cause-and-effect chain causing the problem. If errors in the veterinary care system are not researched to find what caused them, the error rate will continue to rise.
As veterinary care professionals who strive to provide good care for patients, it is of utmost importance that every avenue is taken to ensure that patients receive the very best of care. Errors do and will occur, but it is the responsibility of each veterinarian and every organization to perform thorough studies to find out why errors/events occur, so that solutions/processes can be implemented to avoid similar errors in the future.
The history of root cause analysis (RCA) goes back to the need of the industrial industry to analyze and correct accidents and is also connected to the broader field of TQM (total quality management). The health care industry widely uses RCA as set by the example of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for more than a decade. Clinical teams can look at all the acts related to a harmful incident, or near misses, identify the cause (root), and work to create solutions to prevent these incidents from recurring. Implementing and/ or furthering the use of the Root Cause Analysis in the veterinary care world can also help us to identify the cause or root and to also avoid these errors or incidents from recurring in the animal healthcare realm.
Two important and misunderstood facts concerning root cause analysis are: 1) root cause analysis is a management tool, not a patient care tool even though it is focused on patient safety; and 2) the main goal is to prevent human error, but root cause analysis is designed to examine the entire system and processes. RCA is NOT designed to blame individuals. With this information in mind, let’s look at how a veterinarian can utilize the root cause analysis.
Everyday, the veterinarian professional performs a simple root cause analysis without even realizing they are performing one. A DVM does not just treat symptoms, we look at the sources of pain and work to determine ways to eliminate the cause. The DVM must analyze the total system to determine where the problem is coming from to resolve the question and treat the animal.
The root cause analysis looks to determine the origin of a problem. Specific steps are taken so we can: 1) determine what happened; 2) determine why it happened; and 3) figure out how to reduce the chances of it happening again. There are 3 basic causes to a problem: 1) physical causes; 2) human causes, and 3) organizational causes, and the root cause analysis looks at all three. Many times the RCA will determine there are multiple causes.
The root cause analysis has 5 steps (some sources only list 4):
1) Define the problem (step that some sources do not include)
- What do you see happening?
- Are there specific symptoms – if so, what are they?
2) Data collection
- Everyone must understand the problem before it can be analyzed.
- Include everyone that can add information from front desk to clinicians to help gain a better understanding of the problem
3) Identify or chart causal factors
- What order of events leads to the problem?
- What conditions allow the problem to occur?
To identify causal factors, it is a good idea to employ the “5 Whys” and we will use that techniques in the case studies in the next section. By the time why has been asked 5 times, you will usually be at the root of the problem.By the time why has been asked 5 times, you will usually be at the root of the problem. By the time why has been asked 5 times, you will usually be at the root of the problem.
4) Root Cause Identification – the identification of the underlying reason or reasons for each causal factor
- Why does the causal factor exist?
- What is the real reason the problem occurred?
5) Generate and Implement Solutions
- Once the team has come to a conclusion on what changes are needed, the greatest hurdle may be to make the change and sustain it.
The last point a veterinary professional should remember about root cause analysis, it that the same techniques can be applied to other areas in the practice such as, why is there a large number of no-shows (affects financials, scheduling and more).
Our next section consists of 3 case studies for which we have employed an RCA to determine the root of the incident and ways to avoid the repeating of these type incidents.