Problem: We had re-occurring incidents being reported and our Root Cause Analysis / Reviews of incidents focused on blaming the individual or addressing skills and education gaps. This was creating by default a blame culture which we wanted to move away from.
Measurement: We used control charts to display our data that was split into five key themes which were based on the SHELL (Software, Hardware, Environment, Liveware and Leadership) conceptual model that assists in understanding the relationships between system resources/environment and the human component in the system (the human subsystem).
Analysis: We incorporated the SHELL model into our incident and risk management system, RLDatix and used descriptive statistical analysis to plot our findings and then further analysis undertaken to identify the median and any special causes from the themes that were emerging. All data was displayed on SPC charts.
Implementation: As the focus moved away from the ‘human’, we were able to identify system gaps in non-technical skills which we implemented; obstacles encountered related to staff inclined to go back to blaming individuals but we had strict rules during the reviews; benefits – this methodology impacts the culture.
Results/Discussion: Our reporting culture score improved over time and overall patient safety scores improved; processes and tools – control charts to display findings, which we continue to display our findings and sustain our results. The next steps will be to undertake a deeper analysis into the broad five themes.