Approaches to ensuring quality in the UK health sector and beyond are vast and include root cause analysis (RCA) ( Sarkar, Mukhopadhyay and Ghosh, 2013).It appears that potentially avoidable serious incidents are reoccurring despite investigation and intervention. An initial analysis of serious incidents undertaken by the researchers suggests that despite deployment of root cause analysis and resolutions, many serious incidents reoccur within ambulance and other health care settings, such as hospitals; this gives rise for the main study. At times, it appears that the solutions identified during the RCA are inadequate or ill-advised.
The study focuses on serious incidents, meaning those events where the potential for learning is so great, or the consequences to patients, families and carers, staff or organisations are so significant (serious harm or death). The classification of incidents as ‘avoidable’, learning as ‘obvious’ and consequences on patients, families, careers, staff and organisations as ‘significant’ presents a conceptual challenge in itself, given their subjective nature. This dilemma will be explored further in the paper.
Currently, there appears to be minimal research related to quality and service improvements within the ambulance service (Fisher, Freeman, Clarke, Spurgeon, Smyth, Perkins, Sujan and Cooke, 2015).Drawing upon service improvement, and quality discourse, the researchers will set the context for their future researchers. Training provision for investigators, true root causes being identified and correct actions being implemented (Eshareturi and Serrant, 2016). Current research also suggests that optimal root cause analysis systems and processes are reliant on the type of organisational culture in which they are undertaken. They state it is essential to embrace learning opportunities from system and human failings and share these across the organisation, to ensure service improvements are made as a result of serious incidents; rather than apportioning blame(Rushmer, Kelly, Lough, Wilkinson and Davies, 2003).
The paper will set the direction for this ongoing study, which methodologically will include analysis of root cause analysis investigations reports submitted by an ambulance service over a two year period. The lead researcher is a qualified nurse, and active health professional with responsibility for service quality in the NHS (in roles past and present such as Head of Quality for a health commissioner and provider health organisations). As such, the lead researcher possesses sound knowledge to identify discrepancies in cause and prevention. Due to previous experiences of working within differing health sectors and witnessing avoidable reoccurring incidents, the researcher recognises the opportunity to develop joint approaches with other healthcare settings regarding improving the RCA process. This would improve patient care and experiences but also reduce healthcare costs (Renaud, 2014).
The study forms part of the lead researcher’s professional doctorate research.
The outcome of this analysis will set the agenda for more research in this area particularly around investigators’ understanding of a root cause, their role within the root cause analysis process and the organisational support they receive to either confirm or disprove if there is a correlation between the incorrect root cause being identified resulting in the incorrect actions being implemented.
final_version-Setting_the_direction_for_a_review_of_root_cause_analysis_in_the_ambulance_service.pdf 