RCA Process - Clean_ Safe Care by chenboying


									A) Healthcare Associated Infections Root Cause Analysis (RCA) Process
                                                            Additional materials developed to suport RCA process

                                                    (B) Checklist                                  (E) MRSA
                                                         and             (D) Rapid review                                 (G) RCA review
                                                  (C) Role profile for       checklist                                    meeting roles &
                                                                                                    (F) CDI
                                                      RCA Lead                                                             rseponsiblities
                                                                                                   RCA tools

       Lab results
                                                                           rapid review
                                                                            (RCA Lead)
                                                  Issue governance
    Confirm diagnosis                            alert and assign an
                               Inform                                                                                       RCA review               Notify
     (Microbiologist)                           RCA Lead (Executive                                Gather data
                                                        Lead)                                                                meeting             Executive Lead
                                                                                                                                                     of RCA
                                                                         Identify and inform
                                                                          RCA review team
                                                                            (RCA Lead)
                                                                                                                          Generate RCA                                                                         Sign-off
                                                                                                                                                 Communicate      Report into     Monitor action
     Microbiologist reports diagnosis to:                                                                                  report and                                                                         completed
                                                                                                                                                  allocated       Governance      plan progress
     - Patient's current care setting (e.g. ward / nursing home /                                                          action plan                                                                        action plan
                                                                                                                                                   actions         Structures      and impact
     patients home)                                                                                                                                                                                        (Executive Lead)
     - Infection Prevention and Control Team
     - Doctor responsible for patient care
     - Director of Infection Prevention and Control
     - Nominated Executive Lead for RCA
                                                                                                                      Assign action plan           Commence                                                Feed findings into
                                                                                                                           owner                   delivery of                    Feed identified              themes and
                                                                                                                                                   action plan                    risk factors and          lessons from all
                                                                                                                                                                                     sources of              RCAs to drive
           Immediate patient treatment and infection                                                                                                                                                       organisation and
                                                                                                                                                                                 bacteraemia into
                          control actions                                                                                                                                                                     whole health
                                                                                                                                                                                voluntary fields on
             (Doctor responsible for patient care, care                                                                                                                                                      economy wide
                                                                                                                                                                                    HPA website
                       environment manager                                                                                                                                                                    learning and
             & Infection Prevention and Control Team)                                                                                                                                                         development

                          React                                                                                  Record                                                Respond

Timeline (days)                                                                                                                                                                            Monthly meetings

0                                                                                              2                                             5   (working days)                                       30         On-going to

                                                                                                                                                                                                                       Page 1

(B) RCA Lead Checklist

Activity                                                               Notes

React: Immediate actions

Have the Clinical Team been informed of the incident?

Has an appropriate treatment plan been instigated?

Has the patient been isolated?

Hold rapid review meeting with care environment staff

Have staff in the immmediate area been informed?

Have patient relatives /carers been informed and had
written information?

Identify RCA meeting team

Arrange the RCA meeting

Record: Conduct RCA review meeting

Begin preparing document file for RCA review

Gather data and construct a timeline of events

Identify key issues with patient pathways

Circulate key issues to review meeting team prior to

Present timeline and data gathered

Facilitate discussion about possible cause

Document discussions about possible cause

Facilitate analysis and agree most likely root cause

Agree actions to prevent reoccurrence

Polulate HPA voluntary web pages with risk factors and
possible primary cause

Document action plan with identified leads and timescales
for completion including issues to be raised corporately

Respond: Post review meeting

Release action plan with review dates

Ensure corporate documentation complete

Notify the Executive lead of RCA completion

                                                                               Page 2
(C) Roles and Responsibilities for RCA Lead

                                                              Prepare for RCA investigation

                                                              - Arrange RCA meeting
    Communication and Immediate Actions                       - Scope incident to define whole patient pathway and
                                                              timescale                                                   Learning the Lessons
    - Ensure clinical teams aware of the incident             - Select multidisciplinary RCA investigation team
                                                              including clinical team, governance or risk advisor         - Communicate findings through local governance
    - Ensure the patient / relative / carers have been
                                                              - Identify information required to undertake RCA              committees and staff bulletins
    informed and appropriate treatment commenced
                                                              - Complete data collection (use data gathering tool)        - Communicate findings to wider stakeholders
    - Ensure appropriate infection control measures are
                                                              - Prepare meeting documentation                               ie PCT / SHA / Acute Trusts
    in place
                                                                                                                          - Ensure outcomes, actions and themes are
    - Ensure the incident been documented
                                                                                                                            incorporated into appropriate Trust action plans
    - Inform Governance and risk management teams
                                                                                                                          - Ensure action plan is monitored and actions
    - Ensure that a rapid review is conducted and
                                                                                                                            closed or escalated as appropriate
                                                              Oversee RCA investigation                                   - Ensure evidence of RCA and outcomes are
                                                                                                                            documented and archived for future reference
                                                              - Analyse data and prepare a timeline of events             - Ensure risk factors and possible likely root cause
                                                              - Ensure RCA review team receive paperwork in                 is input into HPA web based system
                                                                advance of meeting
                                                              - Present initial findings and facilitate analysis of
                                                                contributory factors
                                                              - Document findings, recommendations and
                                                                agreed actions
                                                              - Ensure action plans have named leads and
                                                                timescales for implementation

                      React                                                        Record                                                     Respond

Timeline (days)                                                                                                                                          Monthly meetings

0                                                         2                                                           5    (working days)                        30      On-going to

                                                                        Refer to supporting documents:
                                              B) RCA Lead checklist   (D) Rapid Review checklist (E & F) Data Gathering tools

                                                                                                                                                                                 Page 3
(D) Rapid review checklist
Purpose :
Ensure patient safety
Identify and implement immediate actions
Begin data gathering
Activity (visit patient's care environment)                                                        Notes

Patient Factors

Inform patient, relatives/carer of the review

Discuss case with care staff

Review recent antibiotic history

Has appropriate treatment commenced according to policy?

Has screening and decolonisation occurred according to
policy (MRSA bacteraemia only)?

Are invasive devices present (MRSA bacteraemia only).

Identify any non compliance with policy.

Is patient's documentation completed correctly?

Record date and time of isolation/cohort and identify patients
previous location on ward / contact with other patients with C-
difficile / MRSA

Environment (complete where applicable)

Are isolation and hand hygiene prompt notices in place?

Identify any staffing issues

Is there a stock of PPE?

Is there adequate hand hygiene facilities available and are
soaps, gels and hand towel dispeners stocked and in good
working order?

Identify when the last HH audit was undertaken and what
was the compliance

Identify what is the current compliance data for High Impact

Identify when the last cleaning audit was carried out and what
was the result ?

How many days since last bacteraemia/ C difficile on this
care environment?

Identify Immediate actions as a result of the rapid review and communicate to relevant personnel

                                                                                                           Page 4
(G) Root Cause Analysis Review Meeting - Roles and Responsibilities


   The purpose of the RCA group is to undertake a thorough investigation to establish the root cause of Health Care Associated Infections (HCAI) cases
   occurring in hospital/community settings.

   The meeting should ensure that an action plan is generated; actions are assigned and communicated through the relevant governance structures of
   the organisation.

   The RCA group will be the accountable body for ensuring that a robust analysis of all MRSA/ C-difficile is undertaken with the aim to minimise risk of
   further HCAI occurring.


   The RCA group will formally report to the Executive Lead for RCA


   • RCA Lead (Chair)
   • Microbiologist / Infection Control Doctor
   • Infection Control Practitioner
   • Admin support
   • Risk/Performance manager
   • Care setting representative
   • Doctor responsible for patient’s care
   • Others as appropriate

   1. The nominated RCA lead convenes the RCA review meeting within 5 working days of HCAI notification.

   2. The RCA lead forwards all relevant documentation to attendees to preview a minimum of 24 hours prior to the meeting.

   3. The meeting will be formally chaired and conducted and comprise of three parts:

   Part one - Verifying data gathered
   The RCA lead presents the findings of the initial data collection exercise and identifies the key issues.

   Part two - Analysis of findings
   Attendees through discussion and debate analyse the key issues and reach agreement on the root cause.

   Part three - Confirming action plan and follow through
   The chair leads the discussion on identifying actions to be undertaken to address the root causes and the outputs of each action, the timescales for
   delivery and the responsible owner.

   4. Minutes will be taken and Trust RCA documentation including action plan completed and circulated within three working days of the meeting to the
   Trust RCA Executive Lead.


   • To support, steer and contribute to the discussions in part one and two to ensure that required outcomes are delivered.
   • To demonstrate leadership and recognition of the seriousness of HCAI to all clinical staff.

   • To ensure that attendees are conversant with any major strategic imperatives/policy changes that could influence the analysis of the root cause or
   actions thereafter.

   • To ensure that decisions are made in an informed way and communicated in an appropriate manner.

   • To work together as an effective multi disciplinary team which respects the views and contribution of all members.

   • To provide an ‘expert’ contribution to the validation of the key issues/ emerging findings.

   • To be accountable for the decisions reached and to take all reasonable steps to ensure that required actions are conveyed clearly and reported into
   trust governance structures.

                                                                                                                                                            Page 5

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