The latent analysis revealed unexpected results to expose organisational and governance dysfunctions that left the effectiveness of the RCA as an organisational technique to improve patient safety lacking.
First, the application of the RCA was inhibited by language decoys that fragmented the language to a point where information was disregarded and process of gathering
information to inform cause and effect was unclear. In particular, language decoys established a disjuncture whereby organisational goals were blurred and operational imperatives to complete an RCA dominated. Concurrently, language decoys circumvented the disclosure of systemic latent failures because system risks were challenged by multiple accounts of human error that made the distinction between the systemic risk and human error hard to find. In the search for cause and effect and the absence of latent system failures, multi-dimensional blame became the focus in the RCA because issues of familiarly and consensus dominated the investigation of an event
Second, legislative conditions provided a flexible approach to the application of the RCA that sought to find cause and effect. An option was legislatively created to complete the chain of event documents that contradicted organisational directives which explicitly defined how to complete the chain of event documents. As a result, chain of event documents were absent or constructed in a manner that identified multiple active errors and failed to identify latent system failures. This meant only individual failures comprised an investigation of a harm event. Hence, the RCAs’ systemic approach to the analysis of harm departed from organisational policy.
Moreover, the latent analysis revealed that the purpose of the RCA to function as a systematic technique for the analysis of SAC 1 harm and to improve patient safety in Queensland Healthcare facilities is compromised because legislative and organisational agendas are in conflict. In the absence of directions, RCA methodology departs from patient safety agendas. Language decoys circumvent latent system failures, root causes are avoided and recommendations are arbitrarily applied. It is not that there is intent to ignore healthcare directives that support an agenda to improve patient safety; but in search for cause and effect that departs from patient safety ideology, the construction of the RCA is characterised by active errors that impose blame rather than a culture of harm. The social construction of the RCA is limited by an RCA process that does not view harm as a system failure but views harm as a failure of multiple individuals as the doctor, the nurse. The RCA failed to
determine this as a characteristic of culture, or the way we do things around here. The point is that overall RCA teams work in isolation while knowledge and experience of patient harm is abundant and a culture of harm is acknowledged, there is no sharing of information because the RCA applies mono-causal methods (Fahlbruch, 2011). The investigation of patient harm has separated from a systems analysis and patient safety is not addressed in the RCA. In addition, the departure from processes creates an opportunity for heuristic devices
of familiarity and consensus to dominate an investigation. Thus, an anomaly in regulatory documentation announces a systematic process of analysis optional that renders the function of the RCA as a technique to investigate SAC 1 harm compromised.
A deeper theoretical issue emerges that despite a conflict in organisational agendas that inform Queensland Health’s patient safety agenda, the RCA departs from wider theoretical imperatives, a systems approach, to improve patient safety. The final chapter, Chapter 7 goes back to overarching theoretical directives that drive an imperative to improve patient safety; back to the IOM’s (2000) theoretical safety agendas to discuss the challenges of applying a systems approach.
The RCA unlocked Chapter 7:
In closing the research, Chapter 7 ‘lifts the lid on the RCA’ and goes back to principal theoretical ideas that frame patient safety, a systems approach (IOM, 2000). It is discussed here when designing a safer healthcare system for Queensland that draws on safety principals established by international agendas, theoretical safety concepts that underpin the RCA are difficult to translate Nicolini et al., 2011b) and have been lost from practice. While it was identified that opportunities exist in key documents that depart from theoretical agendas more understanding about the social views that comprise this phenomenon are addressed. This chapter discusses the challenges to apply Queensland’s systems approach where safety ideas cannot be predicted through the RCA.
To briefly review, Chapter 5 generated four key theoretical propositions from the manifest analysis. Chapter 6 applied latent analysis to these theoretical ideas that gave focus to a paradox that existed between language decoys, the rhetoric of an organisation’s patient safety policy and the reality of the RCA process that centred on failures of a group and individual practices. It was revealed that legislative and organisational agendas were discordant. In application, this conflict created opportunities for the RCA to depart from organisational policy. While latent analysis presented in Chapter 6 demonstrated that a systematic process of analysis had been avoided through language decoys and heuristic devices, it was also argued that deviating from policy could not be circumvented. This chapter takes this notion further to gain a deeper understanding of concepts that fail to support a systems approach (IOM, 2000), the central ideology to improve patient safety. The underlying argument is that there are conflicting safety agendas in RCAs’ regulatory
documents while organisational documents provide a clear framework for the analysis process. Yet, this is ignored and this needs closer examination. In this Chapter, it is argued that a systems approach is silent in the RCA while there is an illusion that systemic safety agendas are active in the investigation of harm events. The discussion centres on the notion that theoretical safety agendas have not translated effectively in practice because notions of
“conceptual slack” (Schulman, 1993) socially inform the RCA and are central to the predicament.
Section 7.1 briefly re-examines theoretical perspectives as Queensland Health’s organisational safety agendas that underpin the RCA’s systems approach. In particular, theoretical safety ideas recommended by the IOM (2000) report and frame Queensland Health’s systematic process of analysis, are absent in the RCA. As such, complexities that
challenge a systems approach are discussed. Section 7.2 draws on these ideas to argue the challenges to apply the IOM’s safety agendas to the RCA. A matter of translating high reliability concepts (Rochlin, 1996) which as noted, Queensland Health discreetly applies, Normal Accident theory (Perrow, (1984) and a systems/person approach (Reason, 1990) to the RCA are central here. The challenge in this chapter is to address the social characteristics of safety concepts that underpin a systems approach to understand how standardised RCA methodologies systems approach have been ignored. As the discussion develops,
recommendations are provided to progress areas of concern which are united with a determination to advance patient safety in Queensland. Section 7.3 provides the conclusion to the thesis followed by implications for further research and the limitations of the research.
Finally, the thesis proposes the future of the RCA.
7.1 KEY SAFETY AGENDAS AND A SYSTEMS APPROACH
A systems approach was recommended in the IOM report (IOM, 2000) to provide a safer healthcare system and to address error and harm rates. The approach (IOM, 2000) drew on high-reliability concepts specifically Perrow’s (1984) Normal Accident theory and Reason’s system/person approach, to drive a new safety agenda because patient harm was considered similar to other organisational disasters (IOM, 2000). It is argued here, that despite significant safety benefits of theoretical agendas (Tamuz & Harrison, 2006), a systems approach has been difficult to implement because safety agendas are challenged by social and political influences.
In 2005, the RCA was introduced to Queensland Health. In a consistent global manner, safety principals noted above, informed a new patient safety agenda. In part, these ideas frame key regulatory documents that guide the conduct of the RCA, yet a focus of system safety principals is absent in the RCA. To explain this, healthcare’s safety concepts are briefly re-addressed as they inform the RCAs systems approach.
In high-reliability organisations, safety is a priority where a limited number of accidents that result in harm exist. This approach is aspired to by healthcare but not visible in the key documents that inform the RCA. Nonetheless, the view of safety in high reliability organisations is determined by principles where reducing variation, increasing
standardisation and anticipating failures are key concepts (Welch & Jenson, 2007). Further, there is a commitment to safety and to improve organisational design, where design
shortfalls are viewed to manifest human error and this aspect is recognised in healthcare’s patient safety ideas. Returning to safety in high-reliability organisations, safety is achieved
through compliance to standardised rules and organisational procedures (Rochlin, 1993).
Importantly, a culture of rule compliance exists in high-reliability where attendance to rules is obeyed and learning from error is an ongoing process of analysis because adapting processes are a matter of risk that can be avoided (Casler, 2014). As noted, while only some characteristics of high reliability have been bought forward here, they are central ideas that frame the social construction of the RCA. The view is that while patient safety draws on reliability constructs, such as the adoption of legislation to guide the RCA and the provision of organisational rules, procedures and policy, the notion of compliance departs healthcare from high-reliability principles. This notion is central to understand the relationship between the RCA and system failure and disaster (Vaughan, 2004).
Healthcare’s theoretical perspective clearly draws on Normal Accident theory (Perrow, 1984), where harm is predictable because human error cannot be avoided. While this is marginally consistent with reliability concepts where error is recognised, in Normal Accident theory safety principles depart from reliability principles in a number of ways.
These are briefly re-examined. Perrow’s (1984) Normal Accident theory defines interactions between the system and its components and this is central to locating harm causality in healthcare. In Normal Accident theory, issues of standardisation are acknowledged, but a divergence from high–reliability is that safety concepts are obscured by multiple layers of redundant safety processes and levels of authority that shift priorities of rule-based safety. In addition to Perrow (1984) healthcare applies a no-blame approach to lift traditions that blamed healthcare workers for harm events. The no-blame notion supports safety processes such as reporting incidents and analysing incidents without fear of retribution. Further, Reason’s (1990) system/person approach has been adapted to represent the complexity of healthcare services. Fundamental principles remain intact, where a model is applied to define error causation and error management occurs through a series of organisational safety defences to identify active and latent failures. The idea is that human factor principles are mapped to an event to represent the flow of error causation to identify organisational safety risks.
The social assembly of key regulatory documents addresses healthcare’s safety agendas as tightly coupled systems because governance, standards and centralised systems are identified. As noted in Chapter 3, Tamuz and Harrison (2006) argued that although hospitals are complex, comprising of tightly coupled and loosely coupled systems that exist within complex social, political and technical environments, there are multiple
understandings to achieve outcomes. Healthcare functions under conditions of high risk where human factor principles are so complex that a systems approach cannot be
distinguished. Despite this, RCA methodologies draw on safety concepts that underpin notions of high reliability theory to determine how people, policy, environmental or procedural issues contribute to patient harm. The problem is that RCA legislation and organisational policy while providing a framework to inform the investigation of a harm events and to improve patient safety, theoretical safety ideas are avoided.