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Training & supporting frontline staff to deliver effective Root Cause Analysis

Taffy Gatawa Head of Patient Safety and Quality Royal Surrey County Hospitals NHS Foundation Trust discusses Training and supporting frontline staff to deliver effective Root Cause Analysis at today’s conference. In her presentation Taffy discussed in depth:

Training and educating frontline staff in the use of RCA

  • Resource and time
  • Focus on learning and continual improvement
  • Organisational and Individual Commitment
  • Link with Trust values and behaviour

Supporting recognition of patient safety incidents in real time

  • Moving from process to practical clinical experience
  • Simulation training
  • Climate and culture
  • Systems and Process

Supporting staff to understand and analyse error chains

  • Exploration of Human Factors
  • Culture of enquiry
  • Clinical governance processes
    • Mortality Review
    • CLIP analysis
    • Incident review

Identifying Care and Service Delivery Problems

  • Care delivery problems (CDPs)
    • Relate to direct care provision
    • Are about the patient, carer and healthcare staff
    • Active factors
    • Acts of omission / commission

Identifying Care and Service Delivery Problems

  • Service delivery problems (SDPs)
    • Relate to the context in which care is delivered
    • May be about policy and procedures
    • Service configuration
    • Availability of resource
    • Latent factors

Taffy moved on to discussed the Royal Surrey Way and the advantages and limitations of the approach.

Advantages of the Royal Surrey Way:

  • Corporate oversight of process
  • External reporting and communication made easy
  • Facilitates better internal communication and sharing of lessons learnt?
  • Open and transparent process
  • Clear escalation process

Limitations of the Royal Surrey Way

  • Top down approach
  • Lack of ownership at departmental level
  • Communication is not always targeted to the relevant people
  • Centrally driven, therefore risk of conflict of priorities
  • It’s not perfect and so can get better

Taffy Gatawa’s full presentation is available for download at the end of this page

Future related events:

Root Cause Analysis: 2 Day Intensive Training Course
Thursday 9 July — Friday 10 July 2015, London

Tuesday 25 - Wednesday 26 August 2015, London

Tuesday 15 - Wednesday 16 September 2015, London

Tuesday 13 - Wednesday 14 October 2015, London

Wednesday 4 - Thursday 5 November 2015, London

Wednesday 9 - Thursday 10 December 2015, London

Improving Patient Safety in Independent Healthcare
Wednesday 1 July 2015 
Hallam Conference Centre, London

Managing when a Serious Clinical Incident Occurs
Wednesday 8 July 2015 
Hallam Conference Centre, London

Masterclass: Root Cause Analysis for Beginners
Thursday 10 September 2015 
Hallam Conference Centre, London

Reducing & Monitoring Avoidable Hospital Deaths attributable to problems in care
Thursday 8 October 2015 
Hallam Conference Centre, London

Leading your Organisation to Zero-Harm
Thursday 22 October 2015, Manchester

Thursday 10 December 2015, London


Download: Taffy Gatawa"s full presentation

24 June 2015


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