Case Studies

Delivering Root Cause Analysis Training for a CCG

Summary

A North East CCG asked us to help them improve the standard of their serious incident investigation reports. There were experiencing a lack of consistency in the investigation process and the report writing. The CCG established that none of the staff had received any formal training in the root cause analysis process and commissioned us to provide a series of workshops.

The feedback from the sessions was that staff now felt empowered to complete an investigation in a structured and consistent way using recognised tools and techniques to identify contributory factors and root causes.

The Issue

The Head of Patient Safety and Quality for the CCG recognised that the standard of RCA investigations was not great and that there was a lot of inconsistency. This was resulting in investigations having to be repeated and patients and families not getting answers in a timely manner. This was also leading to increased attention from local HM Coroner and the Care Quality Commission. This was having a negative effect on staff morale who were investing a lot of time and energy into completing the investigations.

Our Approach

We arranged for six workshops for 20 personnel ranging from GPs to reception staff and tailored the workshops accordingly:

• introducing national guidance;
• identifying a serious incident;
• building a case from start to finish;
• interview techniques;
• using key tools such as process mapping and the fishbone diagram;
• establishing contributory factors and root causes;
• developing improvement plans; and
• closing a serious incident

Our Action

We made some recommendations to the CCG lead in relation to standardising  their local policy to be align it with national guidance. During the workshops the attendees were spilt into groups so that they were not working with staff they regularly worked with. The workshops consisted of a balanced mix of presentations, video, group work and plenary sessions.

Outcome

As a result of the sessions the staff now feel more equipped to complete a thorough serious incident investigation that provides answers to patients and family; and demonstrates to external bodies that the organisation responds to and is able to investigate at a high level.

Participant feedback

I must say I thought the course was really interesting and the trainer was brilliant.

I felt I needed to tell you that this workshop was possibly the most interesting I have been on, it was extremely informative and would recommend anyone to attend this!

I have to say the trainer was fantastic and she deserves some positive feedback on her delivery of the workshop.