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Improving the Capacity of Healthcare Organisations to Act on Evidence in Patient Safety

Research Questions 
  • What are the practical problems faced by healthcare practitioners doing Root Cause Analysis?
  • What are the challenges in attempting to implement the recommendations produced through the process?
  • Through what process and mechanism can we generate organisational learning from errors in healthcare?
  • What are the challenges of promoting innovation through structured methodologies in a highly professionalised environment such as healthcare?
The project aims to investigate the practical problems and available solutions for healthcare practitioners doing Root Cause Analysis. We aim at furthering the understanding of how this method is applied on the ground, what are the challenges it poses for the investigators and for the organization, whether it is perceived as useful, and whether it generates organisational learning.
The research will be of a qualitative nature and will be conducted by researchers from the Warwick Business School, the Warwick Medical School, and the School of Sociology & Social Policy of Nottingham University. The team will be actively supported by high level international Scientific Advisory Panel composed of academics, healthcare professionals, and safety experts from healthcare and other industries.
  1. To further understanding of how RCA principles are deployed in practice and of the challenges of conducting RCA

  2. To further understanding of how the results of the investigations are disseminated and implemented and whether, through the practice of accident investigation, healthcare organisations learn from their mistakes

  3. To deepen understanding of the factors and conditions that facilitate or hamper the capacity of structured methodologies, such as RCA, to produce sustainable changes in healthcare organisation

  4. To formulate strategies and generate resources to enable healthcare staff to cope better with enacting and enabling RCA enquiries, and with formulating, disseminating and accommodating RCA recommendations. 

Expected outcomes
We expect to produce empirical evidence that will be useful for addressing the main problems confronting the conduction of RCA and the circulation and implementation of RCA recommendations. We also expect to advance the understanding and theorisation of the process of organisational learning in healthcare and the circulation of medical knowledge. The results of the research will be disseminated through publications, documents and a national event for policy makers, practitioners and academics to be organised at the end of the activity. 
Benefits to Society
Patient safety is a priority area for health policy and health service improvement, being a critical standard for assessing the performance of health care providers and representing a key area of managerial and professional responsibility within the clinical governance framework. It has been estimated that one in every ten NHS inpatients experience some form of ‘adverse event’ costing the NHS over £2billion in remedial care every year. Any contribution in this area has direct and visible impact at societal level.
Benefits to Industry
The project will generate a set of practical guidelines on how health care organizations can improve the way they approach the challenges of producing and implementing RCA recommendations. The guidelines will be fed back to the NHS risk-management community, to the NPSA, and to the firms that are carrying out RCA training and will thus have relevance both for policy makers and practitioners. We expect that, following the research, changes will be introduced in how RCA is conducted in the UK and elsewhere, how recommendations are formulated, and how the implementation process is.
Academic Benefits
The research will generate insights and advance theory both on the RCA method, its conduction and its challenges, as well as on the processes of organisational learning from errors in healthcare, the production and use of evidence in organisations, the idea of evidence-based management, and the challenges and politics of promoting innovation through structured methodologies in a highly professionalised environment such as healthcare organisation where high value is placed on professional discretion and autonomy.


Project Team:

Jeanne Mengis (IKON)
Justin Waring (Nottingham)
Jacky Swan (IKON-WBS)
Alessia Contu (WBS)
Peter Spurgeon (WMS)
Visit the project website