CPSI, Root Cause Analysis Workbook - Paediatric Chairs of Canada

CANADIAN ROOT CAUSE ANALYSIS FRAMEWORKAppendix ETeam Membership, Rolesand Responsibilities.1. Leader: someone knowledgeable about the generaltype of event and organizational authority toimplement the process.Attributes:• analytical in that subject areaResponsibilities:• keep team focused on event• provides support for cultural change• support team members in their analysis• remove barriers faced by team members2. Facilitator: quality specialist or risk managerAttributes:• expert in RCA tools and techniques• skilled at group dynamics• skilled at delegation• skilled at group consensus buildingResponsibilities:• coordination of team meetings• keep team focused on event• completion of timelines• ensuring that RCA process is followed• participate in interviews• writing final report (often done by a formal recordingsecretary for the RCA)Responsibilities:• Provide information relevant to the different stepsinvolved in the event• Provide information on the usual process• Help identify contributing factors and actionsrelevant to current practice4. Other staff or consultants:Include outside agencies as appropriate (home care,EMS, vendors, etc.) They provide information that is notavailable to members inside the organization.Attributes:• Specific knowledge of equipment, technology, etc thatmay have contributed to event or may be required foractions.Responsibilities:• Provide expert opinion and knowledge to facilitateidentification of root causes/contributing factorsand/or development of action plans.5. Senior leadership:Attributes:• Authority for decision-making.• Drive the safety culture by example.Responsibilities:• Ensure that actions are implemented once approved.• Ensure that staff members are scheduled away fromnormal duty to participate in RCA.• Ensure that results of RCA are communicated broadly.3. Individuals knowledgeable about subject area:Depending on the RCA type, this will vary. Clinical andnon-clinical staff members (including those involved inthe critical incident and several who were not) providevaluable insight. Suicide events may include physicalplant or architecture staff, housekeeping, nursing andsecurity, etc. Medication events may include pharmacists,biomedical engineering, information technologists,physicians, nurses, unit clerks, technicians, etc. Patientfalls may include physiotherapists, rehabilitation staff,nursing aids, nurses, etc.Attributes:• extensive knowledge of the subject area• credibility within organization• analytical, open-minded• interested53