Root cause analysis in health care: 21 Step Implementation

JC (Joint Commission) has provided a methodology consisting of 4 sections and 21 steps for root cause analysis. In this research, which was carried out to evaluate the applicability of JCs 21 step implementation, it was tried to demonstrate the applicability of a university hospital on the causes of the samples rejected in the biochemistry-microbiology laboratory. Along with the method; "Gantt Chart", "Brainstorming", "Flow Chart", "Fishbone Diagram", "Failure Mode and Effects Analysis", quality improvement techniques and tools were used. In addition, the strength of improvement actions is rated by using an "Action Hierarchy" tool. As a result of the application; the root causes of the rejected samples were determined as insufficient orientation and training practices, applicability of policies and procedures, lack of monitoring and evaluation, inefficient process flow, and lack of equipment. For these identified root causes, a total of 11 improvement actions were determined where 5 (45.5%) strong, 3 (27.3%) intermediate, and 3 (27.3%) were weak actions. An action plan has been developed for these actions. Overall, it was found that the 21 step methodology, carried out in the study, would assist in identifying direct, contributing, underlying and root causes of a problem and planning improvement actions for root causes by providing detailed guidance. With the basic measures presented in the Failure Mode and Effects Analysis, it is foreseen that there will be a 64.5% decrease in overall risk scores. Keywords: Root Cause Analysis, Failure Mode and Effects Analysis, Quality Tools, Clinical Laboratory Services, Rejected Samples