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Military Health System

Course improves patient care by identifying cause of errors

Image of Military Personnel wearing face mask and posing for a picture. Members of the initial group of RCA W3 course developers. Back row, from left: Robin Francis, Army Col. (Dr.) Timothy Switaj, Schandra Carr, Air Force Capt. (Dr.) Alan Bartholomew, and Sylvia Ringmacher; front row, from left: Chad McGrath, Lori Barteau, Air Force Capt. (Dr.) Amy Jiang, Air Force Lt. Col. (Dr.) Renée Matos, Army Maj. (Dr.) Matthew Kemm, and Ashley Parham (Courtesy of Air Force Lt. Col. (Dr.) Renée Matos).

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How do we make – and keep – our military medical treatment facilities safer?

Facilitated by Air Force Lt. Col. (Dr.) Renée Matos, assistant dean of Quality Improvement and Patient Safety at San Antonio Uniformed Services Health Education Consortium, the RCA W3 course was developed to ensure and improve quality care and reduce negative outcomes at MTFs. COVID-19 pandemic restrictions led to an expanded virtual format this year with an unexpected, positive outcome - even greater participation.

"Medical errors impact healthcare safety, quality, costs and the overall well-being of our healthcare team members. When patient safety events occur, all of those things are affected, including how team members feel about that event," said Matos. "The idea is to give the medical system an objective way to look at those events so that they can prevent them from happening in the future."

Borrowing lessons from other industries, a root cause analysis (RCA) is considered the health care industry's best method to move away from focusing on human error (often termed "blame and shame") and move toward focusing on systemic issues or oversights that can lead to error, Matos explained. The latter approach also results in creating a more transparent environment across the organization in which individuals feel safer to participate in the identification of potential sources of error.

At its base, an RCA is taking a patient safety event or mishap, looking at it from all angles and figuring out the root, or main, cause of the event or where it originated.

'The W3' in the course title stands for:

  • What happened?
  • Why did it happen?
  • What are you going to do about it?

The general idea, Matos said, is to avoid the tendency to blame individuals. While instances of overt negligence do occur and should be appropriately addressed, they are rare. The vast majority of medical errors are due to systemic problems.

For health care workers, placing blame on individuals can lead to burnout, low morale, less transparency, and the potential for more errors in the future.

"We understand that humans are fallible, and we make mistakes. We can't expect humans to be perfect, but what we can do is generate a list of recommended actions which are not targeted at the one person who made a mistake," said Matos. "The idea is to address the system and make the system stronger."

Matos explained that the idea behind an RCA is to develop strong corrective action plans.

"How do you get to the root cause, where you're not saying a person failed to do something but asking why they failed to do it," she said.

For recipients of military healthcare, this ultimately results in making MTFs safer by preventing further adverse events. The RCA W3 course, now in its third iteration, was developed with health care workers often-busy schedule in mind.

"Most root cause analysis courses last a full week and are less likely to be attended by those who need them most, the busy clinicians." said Matos. "To do the job right, an RCA team needs knowledgeable clinicians on board and ready."

Picture of military personnel wearing face mask, sitting around a table talking
Attendees participate in a discussion during an RCA W3 course in January 2020. Due to the COVID-19 pandemic and high demand, the current course was broken into three groups and conducted virtually (Photo by: Jason Edwards, Brooke Army Medical Center).

The goal of the one-day RCA course, said Matos, is to instill knowledge and confidence about patient safety and the RCA process to this audience.

"Its format is more conducive to graduate medical education physician trainees and faculty, and also our nurses, allied health, and support staff who don't typically have the ability to take a full week off," said Matos.

Beginning in December 2018, San Antonio Uniformed Services Health Education Consortium, located at Brooke Army Medical Center, offered its first RCA W3 course using a flipped classroom approach, which is a method that allows students to complete readings at home and use class time to work on live problem solving.

The courses are comprised of voluntary civilian and active-duty participants from throughout military medicine with an interest in patient safety, including graduate medical education residents and faculty, nurses, pharmacists, therapists, and administrators.

"In December of 2018, we began with 75 participants and by January 2020 we had 95 participants," said Matos. "There's a lot of administrative work that goes into putting something like that together, but they were wildly successful."

Those first two courses, she said, created the demand for more. For this year's course, the COVID-19 pandemic created a unique problem – the inability to put over 100 people in room together - which required a unique solution.

"We had over 150 people interested in attending the course," said Matos. "We established a virtual platform and created three smaller courses, capping it at around 50 students per course. We completed a course in January, another in March and we have our last course for this year scheduled for May."

An added benefit of these courses being conducted virtually is that it has opened participation from outside of the San Antonio area, including attendees from California and Germany.

Matos said that the feedback so far has been extremely positive, and the courses seem to be doing exactly what they were intended to do.

"People have felt that their confidence in participating in, interviewing people, and actually leading people in an RCA has all improved as a result of this course," said Matos.

A better understanding of the process, she said, leads to these individuals becoming RCA team members at their facilities with the requisite tools and knowledge at their disposal. This, in turn, leads to stronger corrective action plans and greater prevention of future patient safety issues.

"We know trainees practice what they learn, and those practices persist years after they graduate, said Matos. "In the military, we hire 100% of our graduates into our own system, the MHS, so I feel we have a moral obligation to train them and teach them about patient safety and why it matters."

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Last Updated: December 28, 2022
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