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Prakash Chandran (Host): Welcome to the ASHRM podcast made possible by the American Society for Healthcare Risk Management, to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit ashrm.org/membership to learn more and to become an ASHRM member. My name is Prakash Chandran. As you all know, there are many stakeholders and participants in a root cause analysis, but today we're going to focus on one of them, the executive leader who sponsors the RCA process. With us to help us understand the importance of the executive's role and how to best engage with them, are two guests. The first is Karen Markwith, Division Director of Risk Management for Virginia Mason Franciscan Health System, a part of Common Spirit Health located in Seattle Tacoma region. Karen has many years of experience in risk management at large health systems.

She's also an RN with a master's in Jurisprudence and Health Law. Her involvement with ASHRM includes co-authoring the 2016 Physician Office Risk Management Playbook, in 2017, the Healthcare Risk Management Fundamentals Playbook, and is Chairing of the Annual Conference Committee for 2022. Also joining us is Denise Dubuque, VP for Patient Care Services for Virginia Mason Medical Center, a part of Virginia Mason Franciscan Health System. Denise has been with Virginia Mason for 34 years. Denise is a Registered Nurse with her master's degree in Healthcare Administration. She's a Certified Lean Leader completing a two year advanced study and training program in the Toyota Production System. Welcome to the ASHRM podcast. Karen and Denise, so great to have you here today.

Thank you so much for your time. Karen, I wanted to start with you just to set the stage. Can you give us an overview of who is typically at the table for a root cause analysis?

Karen Markwith, RN, MJ, CPHRM, CHSP, CPPS (Guest): Sure. Of course we have to have more than one person, that wonderful executive sponsor. We need to have someone who's facilitating it. Usually that's the risk manager, patient safety person, somebody from quality, all great. They need to be trained obviously into facilitating a root cause analysis. Leadership of the department where unfortunately the event occurred or maybe the service line where it was affected, or maybe both, subject matter experts on the process. You want somebody who knows what should have been done so they can understand and identify the defects. Any medical staff involved. And sometimes, sometimes you want to have the staff involved. It really depends on the incident or the event as we don't want to insert or examine more trauma to the staff that was witness or a part of the event. But if it's reasonable, appropriate, then of course, invite that staff member.

Host: So Denise, I'd love to go into some of the responsibilities of an executive in the RCA process. What specifically can they do to help this be an effective process?

Denise Dubuque, RN, MA (Guest): Thank you Prakash. There's about eight key responsibilities of the executive leader. The first responsibility is really establishing a sense of urgency to solve the problem and then based on the seriousness of it, how quickly does the team need to move to assess solutions. One of the other things that's really important is to just ensure stabilization of the patient and the team.

So say, you know, you were working on a situation in which an unanticipated event happened, maybe a patient passed away that was unplanned. And you're needing to really think about you know, is there a patient need that needs to be addressed urgently? Is there family members that need to be attended to, do you need to stop the line within the organization and determine if you need to put a counter-measure, measures in place quickly?

We often will really quickly poll team members to make sure that they are in a good state after the event has occurred. And just really also looking at situations like, for example, say an event happened in an operating room. Do we have the surgeon go back in and do their next case or that care team go back into the next case?

Because if they did, they may be distracted and not providing their, the best patient care to the, to the patients that follow. The other important role is to lead the red PSA process and really by leading it, we want the leader to be starting with a culture of no blame. We really think it's important at Virginia Mason Franciscan Health to focus on the processes that allowed a situation to occur and not the error of an individual, because it's usually always processes that contribute to an error from occurring. The other things that the executives do are, is they establish priorities and allocate resources as necessary, you know, remove any roadblocks to establishing corrective action plans, escalating to other senior leaders in affected departments as needed. Ultimately the executive leader also approves the root cause determination and the solutions that have been established. And lastly, within Virginia Mason, we also then report to our board and the board holds that executive in terms of do those corrective actions and root cause analysis establish really strong, solid solutions to prevent the problem or the error from happening again.

Karen: Denise, what do you think about the executive leader when it comes to a serious adverse event that leaks into the press and it's their role with the communications department?

Denise: Karen, great question. Obviously there's a very close collaboration that occurs between the communication team to make sure that there is, if this gets to a press level, that there is an organizational approach to sharing information that's very thoughtful and planful. So the executive leader definitely needs to make sure again, that the most senior leaders are involved with that and are coordinating with the communications team.

Host: So Denise, you talked at a high level about those eight key responsibilities, coordinating with the communications team, for a press matter, but could you maybe give us some more concrete examples of how to be successful in this role as an executive?

Denise: I think that the team members really, there are a couple of things that I think are really important. The first again is just really establishing an environment in which that there is a no blame culture and therefore you really need to, when people are coming together, you need to just establish the standard that we really want it to be an open, honest conversation, that you're creating an environment in which team members feel comfortable to be open and honest.

And if they've made an error, to admit their error but really, again, it is that reinforcement and setting the tone at the very beginning of the meeting, that this is about the system level issue, and that we really want to look at what are the processes and systems within our organization that allowed the error to occur. Because most of the time, I think, as I had said earlier, it's really common for a problem to occur because of system issues and process issues, not an error of the individual person.

Host: So Karen, how does sponsorship by an executive increase the effectiveness of a root cause analysis?

Karen: I think the keyword there is effectiveness of that root cause analysis because risk managers or patient safety personnel or quality do not want to continue to do a root cause analysis on the same serious event, adverse event. They want to be able to create change through that root cause with those root solutions.

So the effectiveness of a sponsor is pivotal in understanding accountability, making sure timelines are met, respond to barriers right away to ensure that we continue to move forward. And then of course, hard-wiring of the new process, really making sure that the leaders are part of that department where this hard wiring or system is occurring, have also bought into it and how it's being supportive of the process.

Again, making sure the metrics are good, that they're reasonable, achievable, measurable, sustainable. All of that has to be the enforcement, or we do continue to repeat ourselves and continue to do these root cause analysis on the same unfortunate event. If we have not really changed this, changed the system, changed the culture and they are there attending the meetings and their presence makes it sure how important it is for the system to really hone down on this is serious and we need to respond on a system level with this leaders to make that forcible change.

Denise: Karen I'd like to add on as well to the comments that you just made. I think you really commented to the concept of the rigor of the corrective action plan to make sure that we're really are putting measures in place that prevent the, the error to happen again. The other thing I think that the executive can do as well, is to really encourage the use of multidisciplinary teams and focusing on the event.

So the executive can easily welcome in others to participate in the root cause analysis and the, the generation of the corrective action plan. So, that it's really shared teams resolving solutions. Oftentimes events can have a IT component, or they might have team members that really can help you to do, to do study of what is industry. Just related to a particular process or what is the current thinking on best quality measures? So, those are the type of things that also the executive, I think, kind of can push the team in terms of you know, looking at a more comprehensive assessment of the situation.

Host: Now, Karen earlier, you touched on accountability and I was wondering if you could talk about the broader role executives play in promoting accountability.

Karen: It really is that broad role, because we want to ensure that lessons learned from the event are shared and spread. So, that's a big piece of accountability. Like Denise was sharing, about getting those multidisciplinary teams, getting the other leadership involved, so we have the active role in promoting the culture of safety as well as enhancing it.

So that's really a pivotal role for the executive to share and to show how important this is, this is not something we're just going to roll over and not respond to. We're gonna respond in a very structured manner. We're going to make sure that the story is shared. The lessons are shared, and we actually take those lessons and spread them out to whatever department, as well as any other departments that might think that they can relate to it.

That's so important, as well as actually going back to the employee who might've reported this or been involved in, do that face to face, that warm handoff of you're important and we thank you for reporting it and we're making sure that this doesn't happen again. What do you think?

Denise: Karen, I couldn't agree with you more. I think that the executive leader has a very high level of responsibility in terms of really creating a supportive environment. So as you had commented you know, the first thing is when you sometimes sit down and begin a root cause analysis process, the team members are often just so very hard on themselves.

They feel responsible. Sometimes team members think that they might lose their job. They're embarrassed that they made an error. And so, you know, creating that very supportive environment to thank them for their participation, for their openness and their honesty is really important. The other thing that I often do with teams is I will ask them when we've gotten through the process, if they are willing to share it with their peer colleagues. So, say for example, an event occurred in the operating room, would the operating room nurse or surgical tech be willing to really spotlight their learnings and their involvement in that particular event with their peer colleagues in order to really help the rest of the team benefit from their learnings and really spotlight the work that the organization is doing to prevent that. And then I think the other thing is that we really have to create an environment that it says that says it is okay to share defects, to share mistakes, to share errors so that we all become better as a result of it. And that in turn as Karen noted really creates a culture of safety within the organization.

Lastly, I think it's really, I feel very fortunate to be part of Virginia Mason Franciscan Health, because our board also really participates in this process. And even for myself as an executive, when I present a situation to the board and believe that I have applied with the teams that I've worked with, a high level of rigor; sometimes our board will also really push on us to drive the performance further to a greater level, and to ensure that we really can share that our metrics demonstrate that we have succeeded in a resolution of the situation. So, those accountabilities I think, are, are very helpful in the leader role modeling to the team, our appreciating to the teams that work on any particular event.

Host: You know, like, I guess a more basic question that I wanted to ask, or maybe have you expand on Denise, you know, with that culture of transparency that you're talking about, I imagine that there are many situations that are brought to your attention. So, I'm curious as to how the executive leader makes the determination around when a root cause analysis process should be applied?

Denise: Great question. Actually we apply root cause analysis to any error that occurs or event that is reported within our patient safety system. And so we, we apply root cause analysis quite frequently. As an executive, we usually just work on more serious events. And so for example, I might as an executive work on a topic like gee we've noticed an increase in the number of falls that we're having within the organization or pressure injuries or medication errors or, a retained surgical sponge, something, something significant in error or an unanticipated patient death. So, in all of those serious type of injuries, we apply root, root cause analysis to each one of the events. It's just a standard practice and really allows us to ground our teams and making sure that we're applying a high level of rigor and really understanding the root cause of the event occurring and the contributing factors.

Host: Karen just before we close here today, are there any other examples or anything else that you'd like to share with our audience?

Karen: I think it's important that every system has some type of a structure of when you're applying the root cause analysis process like Denise was talking about. You want to make sure that it's, and it is a time commitment. It's a valuable time commitment, but it is again, taking away from other things. So you want your return on your investment.

So allowing the structure for when you need to escalate this event to the root cause process needs to be some type of structure that leadership is aware of and approves of and as well as where is it going to go from once it gets completed. Is your board going to review it? Are they going to be participating in the process, which is again, the ultimate best practice.

And then there are other forms of analysis that can be used for lesser severity of patient incidents that can be addressed. Those other minor things, that, again, addressing the causal factors and going over to site-based corrective action plans are just as effective. So just again, embrace the process. Look at what type of analysis process you would need and provide a structure for your healthcare system.

Denise: Prakash, I would like to add something as well. I think one of the biggest learnings that I've had as an executive is really when working on a serious event and conducting root cause analysis, to not underestimate the emotional component that events or errors have on our team members. I continue to be humbled by the level of responsibility and accountability that our team members feel when something has not gone as planned for a patient. And so the team members really carry an incredibly high burden emotionally. And it's really important, I think, as leaders to make sure with every event that happens, that we pause and we check on the teams and we check in on those that are involved, to make sure as an organization that we're doing everything we can to support them emotionally as we go through the process of a root cause analysis and resolving a situation.

Host: Well, Karen and Denise, this has been a truly insightful conversation. I really appreciate your time today.

Karen: Thank you so much.

Denise: Thank you Prakash. It was a pleasure.

Host: The ASHRM podcast was made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit ashrm.org/membership to learn more and to become an ASHRM member. My name is Prakash Chandran. Thank you so much for listening and we'll talk next time.