Presentation
HE17 - Safe Organization and Analysis and Redesign (SOAR): Application of HFE to Redesign the "RCA"
SessionPoster Session 1
DescriptionRoot cause analysis (RCA) is a systematic process to analyze adverse events and near misses. Over the past decade experts began to question its effectiveness in health care, despite a structured approach for RCAs. One of the main criticisms of “Root Cause Analysis” – the words promote linear thinking toward a single root cause when most events are complex and have multiple contributing factors. The Enterprise Patient Safety Department has re-engineered this critical function applying a Human Factors Systems Engineering Lens to assessing safety events –Safe Organization Analysis and Redesign (SOAR).
SOAR is a 6-step process that promotes a systems engineering lens to event analysis rather than a singular root cause. SOAR's steps include event review to identify harm events, in depth review of the event, confirmation and consensus of the facts concerning the events, generating solutions, implementing solutions, and evaluating and monitoring for sustainability. The SOAR process is also guided by the following principles that encourage human factors systems thinking; use data when available to understand the contributing factors, focus on system factors rather than individual, triangulate data with observations and interviews, and inform solutions with best practices from literature, patient safety organization (PSOs) and high performing peer institutions.
The SOAR process provides a mechanism for anyone in the organization including front line staff as well as the C-suite to escalate safety concerns through event reporting. Additionally SOAR gives front-line a voice that is heard and actioned upon, facilitates Implementing change that is sustained rather than a “band-aid” fix, provides visibility of safety concerns to leadership so appropriate and timely actions are taken, holds leadership and teams accountable to act on the organization's values.
SOAR is a 6-step process that promotes a systems engineering lens to event analysis rather than a singular root cause. SOAR's steps include event review to identify harm events, in depth review of the event, confirmation and consensus of the facts concerning the events, generating solutions, implementing solutions, and evaluating and monitoring for sustainability. The SOAR process is also guided by the following principles that encourage human factors systems thinking; use data when available to understand the contributing factors, focus on system factors rather than individual, triangulate data with observations and interviews, and inform solutions with best practices from literature, patient safety organization (PSOs) and high performing peer institutions.
The SOAR process provides a mechanism for anyone in the organization including front line staff as well as the C-suite to escalate safety concerns through event reporting. Additionally SOAR gives front-line a voice that is heard and actioned upon, facilitates Implementing change that is sustained rather than a “band-aid” fix, provides visibility of safety concerns to leadership so appropriate and timely actions are taken, holds leadership and teams accountable to act on the organization's values.
Event Type
Poster Presentation
TimeMonday, March 314:45pm - 6:15pm EDT
LocationFrontenac Foyer
Digital Health (DH)
Simulation and Education (SE)
Hospital Environments (HE)
Medical and Drug Delivery Devices (MDD)
Patient Safety and Research Initiatives (PS)