Root Cause Analysis (41359)

Learning Objectives:

• Understand how Root Cause Analysis links with Clinical Incident Management and Quality Improvement as per the Clinical Governance Framework and Standard 1 NSQHS second edition
• Understand the policy and legislative requirements of undertaking a Root Cause Analysis
• Have a practical understanding of the steps of the RCA process
• Develop skills in conducting staff interviews to identify the sources of clinical process failure
• Be able to develop recommendations which can be tested using plan, do, study, act cycles
• Be able to formulate an implementation plan to ensure recommendations drive continuous improvement in patient quality and safety

MPH (Hons), Grad Cert Med Ed, RN, RM

Adjunct Associate Professor University of Sydney School of Public Health, Faculty of Medicine and Health

Director, Improvement Academy

Bernie Harrison is the Director of the ACHS Improvement Academy. She has over 30yrs experience in health care, as a clinician, researcher and quality and safety (Q&S) expert. She has extensive experience in designing and delivering Q&S training programs in the Asia pacific region. Her training in quality improvement and patient safety occurred in the USA in 2001 and 2010 as a Fulbright Scholar. She has extensive experience in health care system redesign and has published a Breakthrough Collaborative (Harrison et al Vox Sanguinis 2014) in improving red cell transfusion in the elective surgical setting. She co-authored the Quality in Australian Health Care Study (MJA 1995), the most cited paper in the journal’s 100yr history. Her previous positions include: Executive Director of Hospital Performance for the National Health Performance Authority and Director in the NSW Clinical Excellence Commission. Her clinical experience as a registered nurse and midwife in the UK and Australia: maternity and child health , intensive care, aged care and mental health.