B3: Applying quality improvement science to root cause analysis
to ensure effective implementation of recommendations

Monday 25 July 2022 | 13:20-14:35

Format: Workshop
Stream: Safety
Content filters: Features discussion of improvement methodology

Sentinel event review and Root Cause Analysis are powerful methods for understanding causes of failures in systems that can lead to unsafe care. Part of this methodology requires providing recommendations for systems improvement. It is not uncommon for recommendations to be incompletely implemented, have low levels of effectiveness and/or not be fit for purpose.

This workshop will provide you with theories and practical skills in how to improve the quality of recommendations. It will also draw on human factors theory and Deming’s principles of Plan Do Study Act cycles to maximise the success of implementation of recommendations.

After this session, participants will be able to:

  • Understand how to develop ‘strong’ recommendations and change strategies

  • Gain in-depth knowledge of how to test recommendations using PDSA cycles to understand when they work and when they fail, prior to full implementation

  • Understand the methods for measuring PDSA cycles

  • Know how to develop a project plan to ensure recommendations are implemented in a timely manner.

Bernie Harrison, Australian Council on Healthcare Standards; Australia

Peter Hibbert, Australian Institute of Health Innovation, Macquarie University; Australia