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From analyses to actions

Now it's time for your organization to take the recommendations from your rich analytic work and implement them to improve the underlying care systems to better ensure patient safety.

Implement an action plan

A responsible individual with the authority to act, not a team or committee, should be responsible for ensuring implementation of all the corrective actions. It is not ideal to have multiple individuals or a committee assigned this responsibility because it can dilute accountability and undermine the probability of successful implementation.

Establish process or outcome measures for each action
  • Each action identified by the review team should have a process or outcome measure identifying what will be measured, how it will be measured, the expected compliance level, and the date it will be measured. It is usually helpful to recommend both process and outcome measures.
  • An individual should be identified who will be responsible for measuring and reporting on action effectiveness.
  • Try to strike a balance between the precision and accuracy of your measures and what conclusions they will permit.
Provide feedback to the CEO and board

For the RCA² process to be successful, it is critical that it be supported by all levels of the organization including the chief executive officer and board of directions. Each action recommended by a review team should be approved or disapproved, preferably by the CEO. If an action is disapproved, the reason for its disapproval should be documented and shared with the RCA² team so that the constraint preventing implementation can be understood and an alternative action developed by the team.

Provide feedback to all parties

In addition, present the team's work to leadership of the service/department, staff involved, patient and/or patient’s family, the organization, and the patient safety organization (if relevant). Feedback to the organization as a whole helps build or reinforce a culture of safety and reporting, permitting staff to see the improvements that result from these reports.