Improving RCA performance: the Cornerstone Award and the power of positive reinforcement

Abstract

Implementing a non-monetary recognition award that was tied to specific improvement goals greatly improved the timeliness and quality of the RCA reports in the Veterans Health Administration System.

Patient Safety Reporting Systems: Sustained Quality Improvement Using a Multidisciplinary Team and “Good Catch” Awards

“…A similar nonmonetary award tied to specific improvement goals implemented by the Veterans Health Administration demonstrated an improvement in the timeliness and quality of root cause analysis (RCA) reports. 23 While that process was more centralized than the unit-based process we describe, both fostered a culture that valued reporting but more importantly, proactively used reports to drive quality improvement. Though it is not possible to isolate and measure the impact of that process on safety culture, it did positively contribute to safety culture because of its sustainability, as did ours.…”

Medical error, incident investigation and the second victim: doing better but feeling worse?

“…As a result, incident investigation has become a routine part of the hospital's response to an adverse event 1. In the USA, the Joint Commission's Sentinel event policy and the Veterans Affairs hospitals' adoption of root cause analysis have made root cause analysis standard operating procedure 2. Armed with the results of these investigations, research and quality improvement efforts are now taking on system improvements required to create a safer healthcare environment.…”

Rebalancing risk management—Part 2: The Active Risk Control (ARC) Toolkit

“…Additional research will be required to confirm the findings of this study and to track the outcomes in terms of risk control implementation, sustainment, and success. Work done in the US Veterans Health Administration suggests that a nonmonetary incentive program may also help to improve the proportion of risk assessments that result in the selection of at least one strong risk control option . It may be that combining this pull‐based approach with the push‐based approach of the ARC Toolkit could improve the value of both.…”