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Transforming root cause analysis through Enterprise Safety Management: Enhancing patient safety and operational efficiency

A Texas-based health system’s experience highlights the vital role of root cause analysis (RCA) in advancing healthcare safety and the transformative results of ECRI’s consulting partnership. RCA is a cornerstone of organizational learning and harm prevention—when done well, it enables timely, thorough, and effective problem solving that protects patients and strengthens system reliability. The ECRI team helped build a more consistent, standardized RCA process—one that ensures patient safety events are examined with clarity and purpose, leading to deeper insights, sustainable improvements, and a stronger culture of safety across the organization.

Situation

The organization wanted to strengthen the effectiveness and consistency of its RCA process following patient safety events and near misses. While the organization already had an RCA framework in place, the process varied across teams, leading to differences in action planning and follow-through. These variations made it difficult to capture learnings consistently and limited the system’s ability to drive enterprise-wide, sustainable improvements. The organization also wanted a proactive, objective assessment of their overall safety program.

Approach

Analysis Methodology

In early 2025, ECRI conducted a comprehensive Enterprise Safety Management (ESM) analysis, a method to assess key elements of their safety infrastructure, including tiered safety huddles, great catch reporting and other proven strategies. Inputs for the analysis included the results of an organizational self-assessment, staff perceptions from recent culture of safety and health equity surveys, pertinent policies and procedures, and a multiday on-site visit that included interviews with stakeholders regarding the established patient safety processes.

Enterprise Safety Management Modules

  • Peer Support for Team Members
  • Communication, Apology, Review, and Resolution with Patients and Families
  • Root Cause Analysis of Harm Events and Near Misses
  • Great Catch Reporting and Recognition
  • Patient-Reported Safety Concerns: Reporting, Response, and Action
  • Safety Event Reporting
  • Tiered Safety Huddles

Key Findings

ECRI’s ESM analysis identified notable strengths, including a strong commitment to quality and safety, resilient leadership, psychological safety, effective communication structures such as tiered huddles, and a demonstrated dedication to health equity.

At the same time, the review uncovered 18 system-level challenges within the RCA process, spanning organizational factors related to people, processes, tools and technology, and culture. Key issues included:

  • Lack of overarching RCA policy with defined event selection criteria
  • RCAs led by individuals with varying levels of training and expertise
  • Inconsistent accountability for follow-up actions
  • Limited monitoring and closure of risk-reduction strategies
  • Fragmented integration between patient safety and quality teams

ECRI concluded that establishing streamlined policies and clearer governance could enhance event selection, strengthen root cause identification, and improve the development and measurement of action plans.

Solutions

In April 2025, ECRI facilitated a participatory design session with the goal of designing a future-state RCA process that was scalable, evidence-based, and aligned with the organization’s operational culture to meet the health system’s needs. During this session, nine solutions were developed, falling into the following areas:

  1. Event Selection: Use the Causal Analysis Determination Tool to identify events for RCA
    Anticipated Impact: Ensures that the right events undergo appropriate cause analysis, minimizing the risk of recurrence. This will allow safety teams to invest the right amount of time and resources into events undergoing RCAs, more effectively managing workload.
  2. Notification and Escalation (Leadership Engagement): Obtain leadership commitment to RCA. Notify executive leaders and the Board of an event using an evidence-based format.
    Anticipated Impact: Ensures timely and informed decision-making by leadership and provides foundational support for developing a just culture.
  3. Investigative Interviews: Utilize an evidence-based process for conducting investigative interviews.
    Anticipated Impact: More accurate data collection, improved understanding of the context of human error to support better system design, and stronger causal statements that lead to effective interventions/RRSs.
  4. Risk-Reduction Strategies (RRSs): Consider all domains of the system when brainstorming change actions. Use evidence-based methods to measure the potential impact of proposed RRSs. Ensure that the owners responsible for the implementation of RRSs are involved. Assess RRSs quantitatively and objectively based on potential impact. Communicate planned RRSs to the appropriate councils/committees for resources and accountability.
    Anticipated Impact: Considering all domains of the system when brainstorming change actions and using evidence-based methods to measure the potential impact of proposed RRSs will lead to more effective and sustainable interventions.
  5. Staff Training: Employ a team-based approach with a single leader and oversight by patient safety staff. Develop and train patient safety and quality staff to lead causal analyses, providing a systems thinking framework. Train all staff on the purpose and importance of RCAs.
    Anticipated Impact: Results in a team of qualified staff who can effectively utilize the tools provided and identify system factors beyond human error.

Future Implications

The implementation of ECRI’s ESM program is expected to significantly enhance patient safety and operational efficiency, ultimately benefiting the health system and its patients.

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