Jurnal Administrasi Kesehatan Indonesia Volume 7 No 1 January-June 2019

Published by Universitas Airlangga

doi: 10.20473/jaki.v7i1.2019.18-24

ROOT CAUSE ANALYSIS ON HOSPITAL STANDARDS AND

JOINT COMMISSION INTERNATIONAL STANDARDS:
A COMPARATIVE STUDY
Analisis Perbandingan antara Analisis Root Cause pada Standar Rumah Sakit dan
Standar Joint Commission International: Sebuah Studi Perbandingan
*Bella Putri Lanida1, Tito Yustiawan2, Sylvy Medtasya Dzykryanka3
1Faculty of Public Health, Universitas Airlangga, Indonesia
2Faculty of Public Health, Universitas Airlangga, Indonesia
3 Mother and Child Hospital of Kendangsari Merr, Indonesia

*Correspondence: [email protected]

ABSTRACT

Background: Healthcare Associated Infections (HAIs) are infections that patients caught during medical
treatment and health care. Prevention and control of infection will lead to patient safety, which ultimately has an
impact on efficiency, management of health care facilities, and improvement of service quality. Infection can be
controlled by identifying the causes. One method to achieve this goal is the Root Cause Analysis (RCA).
Aim: This study aims to analyze the implementation of Root Couse Analysis (RCA) conducted by the Infection
Prevention and Control Committee at the Mother and Child Hospital of Kendangsari MERR Surabaya.
Method: This is a quantitative observational research that utilizes descriptive data analysis. This study is a
cross sectional study and its results are presented narratively.
Results: Results show that the Joint Commission International Standard 2015 version of RCA was not fully
implemented at the Mother and Child Hospital of Kendangsari MERR Surabaya. Some methods, such as the
fishbone and Plan-Do-Study-Action (PDSA), were not implemented. Limited resources became the contributing
factor.
Conclusion: Infection Prevention and Control Committee at the Mother and Child Hospital of Kendangsari
Merr Surabaya has implemented 9 out of 21 RCA steps of the Joint Commission International Standard 2015.
The hospital needs to use other methods as an addition to the 5 Why’s in implementing RCA, such as fishbone
diagrams and Plan-Do-Study-Action (PDSA), for problem solving planning.

Keywords: Root Cause Analysis (RCA), HAIs, Infection prevention and control.

ABSTRAK

Latar Belakang: HAIs adalah infeksi yang terjadi pada pasien ketika menerima perawatan dan pelayanan
kesehatan. Pencegahan dan pengendalian infeksi akan mewujudkan adanya patient safety yang pada
akhirnya berdampak pada efisiensi, manajemen fasilitas pelayanan kesehatan dan peningkatan kualitas
pelayanan. Insiden infeksi yang terjadi harus dikendalikan dengan melakukan indetifikasi sampai
ditemukananya penyebab dari peristiwa atau masalah tersebut. Sehingga suatu organisasi dapat
menggunakan teknik Root Cause Analysis atau RCA yang dapat diaplikasikan untuk mengatasi kondisi
tersebut.
Tujuan: Penelitian ini bertujuan melakukan analisis terhadap proses pelaksanaan Root Couse Analysis (RCA)
di Komite PPI RSIA Kendangsari Merr Surabaya.
Metode: Jenis penelitian ini adalah observasional dengan analisis data deskriptif pendekatan kuantitatif karena
hasil penelitian disampaikan secara naratif. Ditinjau dari segi waktu penelitian termasuk penelitian cross
sectional.
Hasil: Hasil analisis kesesuaian tahapan RCA yang ada pada Joint Commission International Tahun 2015
dengan pelaksanaan RCA di Komite PPI RSIA Kendangsari Merr tidak semua dilakukan oleh Komite PPI.Hal
tersebut disebabkan karena kurangnya applikasi metode lain seperti fishbone dan metode Plan-Do-Study-
Action (PDSA), serta terdapat kerterbatasan sumber daya yang dimiliki oleh RSIA Kendangsari Merr Surabaya.
Kesimpulan: Komite PPI RSIA Kendangsari Merr Surabaya telah melakukan 9 langkah RCA dari 21 langkah
yang ada pada standar Joint Commission International Tahun 2015. Rekomendasi untuk rumah sakit adalah
menggunakan metode lain selain dari the 5 why dalam pelaksanaan RCA seperti diagram fishbone dan
metode Plan-Do-Study-Action (PDSA) untuk perencanaan pemecahan masalah.

Kata Kunci: Root Cause Analysis (RCA), HAIs, Pencegahan dan pengendalian infeksi.

Received: 17 October 2018 Accepted: 6 February 2019 Published: 23 April 2019

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 Jurnal Administrasi Kesehatan Indonesia Volume 7 No 1 January-June 2019
Published by Universitas Airlangga
doi: 10.20473/jaki.v7i1.2019.18-24
INTRODUCTION quality. The Mother and Child Hospital of
Kendangsari MERR Surabaya is one of the private
Infectious disease is one of health problems hospitals specifically aimed to provide health
in various countries in the world, including services to mothers and children, ranging from
Indonesia. Issues of infectious diseases has been basic, specialistic, and subspecialistic health
frequently bought up in various international forums, services.
such as the Asian Pacific Economic Committee The changes of infectious disease patterns
(APEC) and the Global Health Security Agenda at the hospital and shifts of economic risks require
(GHSA). Healthcare Associated Infections (HAIs), systematic efforts of infection control. This means
for instance, have a direct impact to the country's that the Infection Prevention and Control Committee
economic expenses (Ministry of Health of the and trained professionals have to be able to collect
Republic of Indonesia, 2017). HAIs are infections data and run education and consultation programs,
that patients get when they receive medical as well as integrated infection prevention and
treatment and health care. HAIs are caused by control measures. Taking this into consideration,
infectious agents, including bacteria, fungi, viruses, this study aims to analyze the implementation of
and other types of pathogens (Almeida, 2015). HAIs Root Cause Analysis (RCA) at the Mother and Child
are a significant cause of morbidity and mortality on Hospital of Kendangsari MERR Surabaya as part of
patients receiving health care, and the direct and infection prevention and control efforts.
indirect costs of these infections use up limited
financial resources allocated to health service METHOD
delivery (Nazir and Kadri, 2014).
In 2007, the Centers for Disease Control This is an observational research in which
(CDC) and Healthcare Infection Control Practices data collection was done through observation
Advisory Committee (HICPAC) recommended 11 without any treatment to the object. This study uses
main components that must be implemented and descriptive data analysis with quantitative approach
adhered to as standard precautions. The 11 main because the results of the study are delivered in
components are hand hygiene, personal protective narration. In regard of time of the research, this is a
equipment (PPE), decontamination of patient care cross-sectional research because the variables are
equipment, environmental health, waste measured and observed at the same particular time.
management, linen management, health care The study was conducted at the Mother and Child
workers’ protection, patient placement, respiratory Hospital of Kendangsari MERR Surabaya,
hygiene/ethics of coughing and sneezing, safe especially at its Infection Prevention and Control
injecting practices, and safe practice of lumbar (IPC). The study took place from August 2018 to
puncture (Ministry of Health of the Republic of September 2018 utilizing in-depth interviews and
Indonesia, 2017). document observation, as an addition to
Infection prevention and control programs observation, for the data collection. Primary data
can be carried out in health facilities as a solution to were obtained from in-depth interviews with
prevent HAIs. According to Nazir and Kadri (2014), members of the committee, and secondary data
hospital infection control programs can prevent 33% were obtained from documents owned by the
of nosocomial infections. The main goal of an committee. Data collected were then analyzed using
infection control program is to reduce the risk of content analysis method by comparing the results of
infection during the hospitalization period. Based on research with literature review.
the Regulation of Minister of Health of Republic of
Indonesia No. 27 Year 2017, Infection Prevention RESULTS AND DISCUSSION
and Control (IPC) is an effort to prevent and
minimize the occurrence of infections in patients, HAIs can actually be prevented if health
officers, visitors, and the community surrounding facilities carry out infection prevention and control.
health care facilities. The nosocomial infection prevention requires an
One of the infection prevention and control integrated program that can be monitored by
activities is the implementation of risk grading in involving its main components (Nazir and Kadri,
response to occurence of infection. Risk grading 2014). Prevention and control are done to minimize
aims to separate the risk of unacceptable infections the infection risk of officers, visitors, and
from the risk of tolerable infection. These risks must communities surrounding the health care facilities
be evaluated consistently. Risks are usually by establishing a particular committee at the
analyzed by combining estimated consequences hospital. It is in compliance with the Regulation of
(also described as a severity or an outcome) and Minister of Health of Republic of Indonesia No. 27
possibilities (frequency or probability) in the context Year 2017 about Infection Prevention and Control,
of existing control measures (Dumbrava and Iacob, hereinafter abbreviated as IPC.
2013). Based on the Regulation of Minister of
Health of Republic of Indonesia No. 27 Year 2017, Composition of IPC Committee
calculating risk value, or risk grading, is useful to Table 1 explains the results of document
determine the next steps to be taken, namely a review regarding the committees of infection
simple investigation or Root Cause Analysis (RCA). prevention and control at the Mother and Child
Infection Prevention and Control will protect Hospital of Kendangsari MERR Surabaya.
the community and establish patient safety, which in
turn has an impact on the efficiency of health care
facilities management and improvement of service

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 Jurnal Administrasi Kesehatan Indonesia Volume 7 No 1 January-June 2019
Published by Universitas Airlangga
doi: 10.20473/jaki.v7i1.2019.18-24

Table 1. Committee Structures. Implementation of Root Cause Analysis (RCA)

Root Cause Analysis (RCA) is a systematic
Position n
and causal analysis that focuses on finding the
Committee chairman 1 lowest failure rate. However, there are three
Committee secretary 1 constraints in implementing the process. First, lots
Infection Prevention Control methods and tools of RCA are complex and difficult
1 to use. Second, many RCA methods or tools require
Member (IPCM)
Infection Prevention Control Nurse special softwares resulting in limited access and
1 significant amount of initial capital investment.
(IPCN)
Infection Prevention Control Link Finally, some methods or tools also require
7 adherence to very rigid structures that limit creativity
Nurse (IPCLN)
Infection Control (IC) 8 and risk possible loss of the true root causes (York
et al., 2014).
n 17 Root Cause Analysis is known to be a
Source: Data from Comittee of Prevention and Control of Infection reactive approach because it is identified after a
at the Mother and Child Hospital of Kendangsari MERR Surabaya
problem arises. RCA identifies all system failures,
It can be seen from the table that IPCLN has humans, or combinations of both that cause
seven members from different units, such as problems. The benefits of comprehensive RCA
inpatient nurses, Verlos Kamer (VK), baby room, include the identification of permanent solutions,
outpatient installation, Emergency Room prevention of failure recurrence, and introduction of
Installation, Operating Room and Neonatal Intensive logical problem-solving processes which apply to
Care Unit (NICU). Meanwhile, IC has eight problems and misconducts of all sizes
members consisting of laboratory units, pharmacy, (Bhattacharya, 2014). The results from in-depth
Central Sterile Supply Department (CSSD), interviews and document observations regarding
environmental and household health, morgue, RCA implementation at the Mother and Child
hospital facilitiy maintenance unit, nutrition, and Hospital of Kendangsari MERR Surabaya were then
medical records. Based on the suitability analysis of analyzed with 21 RCA steps issued by the 5th
human resources and according to the Regulation Edition of the Joint Commission International
of Minister of Health Regulation No. 27 of 2017, the (Buczkowski et al., 2015).
personnel allocation has met the requirements.
Nevertheless, there are still weaknesses in terms of Organize a team
double allocation, for instance the position of Root Cause Analysis process must starts
chairman in the IPC and IPCO is carried out by the first with forming a team that consists of members
same person in the Secretary and IPCN. from all layers of staffs who have basic knowledge
of the specific areas involved (Shaqdan et al.,
Standard Operating Procedures of Infection 2014). The IPC Committee at the Mother and Child
Prevention and Control Hospital of Kendangsari MERR Surabaya has
The U.S Environment Protection Agency and established its own team to conduct RCA. The team
the European Medicines Agency define Standard consists of one person as team leader, another one
Operating Procedures (SOP) as a series of detailed as secretary, and six people as members of various
written instructions or document routines or units involved. The number of RCA team members
activities in an organization to achieve the uniform at the hospital is in accordance with the statement
performance of a particular function. Based on in- of Charles et al. (2016) which says that the team
depth interviews conducted with IPCN and review of must consist of four to six doctors, supervisors, and
documents on the types of SOP in the infection quality improvement experts with basic knowledge
prevention and control, there was no SOP for RCA. of certain areas of interest.
Results of conformity analysis based on the
Regulation of Minister of Health No. 27 Year 2017 Define the problem
show that the types of SOP used by the committee The second process in responding to
were in compliance. However, the committee did not problems is by defining the problem or incident that
have SOP for health employees or protection for occurred. A good definition is done when describing
health workers. what is wrong and focusing on results, not why the
SOP sheet format prepared by IPC results occur. Based on the interview with the
Committee at the Mother and Child Hospital of Infection Prevention and Control Nurse (IPCN), the
Kendangsari MERR Surabaya was in accordance RCA team conducts meetings to discuss about
with the format issued by the United States infectious incidents that occurred. However,
Environmental Protection Agency (2007), but there document review yields no result on any record of
were several inappropriate formats. First, the SOP definitions as why the infection occurred.
covered types of division, types of data, and reports
produced in carrying out the procedures. Second, Study the problem
the method of quality control was used to The third process is collecting information
demonstrate the performance success. Third, the about the incident that the team can use as a
bibliography was used as a guideline for formulating starting point. The Mother and Child Hospital of
the SOP. Kendangsari MERR Surabaya, based on the
document review, has collected information, such as
statements from and observations of the people
closest to the problem, as well as those who were

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doi: 10.20473/jaki.v7i1.2019.18-24

indirectly involved such as doctors, nurses, infection at the Mother and Child Hospital of
operating room personnel, and clinic personnel. IPC Kendangsari MERR Surabaya which value is set to
Committee also has evidence in the form of photos be ≤ 2%.
as documentary evidence, documents from medical
records, operating room registration, tool usage Design and implement immediate changes
schedule, service schedule, results of tool swabs, The Joint Commission International 2015
and other laboratory results. stated that health care in problematic situation can
cause potentially serious results that may endanger
Determine what happened the patient. Thus, a quick solution or first treatment
The fourth process is to designate the may be needed temporarily to alleviate the problem
problem by asking 5W1H questions that are while the team will continue to work to find the root
important and relevant to the incident (Shaqdan et cause. The Mother and Child Hospital of
al., 2014). Mother and Child Hospital of Kendangsari MERR Surabaya, based on the
Kendangsari MERR Surabaya has carried out this document review, has taken a temporary action to
fourth stage. This is evidenced from the results of overcome incidents by immediately swabing the
interviews with the officers involved and from the device when the infection occured.
chronology table or tabular timeline that has been
made by IPCN. According to Nicolini, Waring and Identify which systems are involved in the root
Mengis (2011), the first major challenge for RCA causes
investigation is gathering information and evidence. The next step is to identify the hospital
After the reported incident has been assessed and system involved in the root cause. The system
investigated, RCA directs the company's manager factors are categorized according to organizational
or local patient safety leader to be responsible for functions or processes carried out by the
collecting more detailed information that serves to organization. These processes involve human
strengthen the report contents and to gather resources, information management, environmental
evidence about actions against the problem. management, leadership and organizational culture,
and encouragement of communication and clear
Identify contributing process and factors priority communication. The Joint Commission
At this stage, IPC Committee carries out the International 2015 stated that fishbone diagram is
identification process of activities involved. The RCA very helpful in categorizing and visualizing various
can be executed using various tools in determining systems or problems that have contributed to the
the cause of the problem, such as the analysis of 5 incidents. Categories within this diagram include
WHYs, fishbone, causal diagrams, and pareto people, procedures, equipment or materials,
charts (Shaqdan et al., 2014). The Mother and Child environment, and policies. The Mother and Child
Hospital of Kendangsari MERR Surabaya, based on Hospital of Kendangsari MERR Surabaya, based on
the document review, has carried out the fifth stage the document review, has not applied fishbone
using the 5 WHYs, but this has not been able to be diagram method.
used to answer the questions about the process and
relevant factors. Prune the list of root causes
The Joint Commission International 2015
Identify other contributing factors stated that if the causal factors have been
The next step is to determine the contributing determined, each cause must be analyzed using
factors beyond the process which consist of human logic-based reasoning skills to determine the main
factors, equipment factors, and factors related to cause. The IPC Committee has not clearly stated
information, as well as controlled or uncontrolled which was the main cause of the incidents because
environmental factors. Fishbone diagrams can help they do not have the list of factors that cause the
to highlight many factors involved in an incident. incidents. It happened because the IPC Committee
Based on the document review, the Mother and only used the 5 MHYs method, so the factors
Child Hospital of Kendangsari MERR Surabaya has cannot be comprehensively found.
not done this step because it only uses the 5 WHYs
method. Confirm root causes and consider their
interrelationships
Measure—collect and assess data on proximate The cause of the incident or root problem
and underlying causes usually consists of more than one cause. The
Data collection is combined to determine Mother and Child Hospital of Kendangsari MERR
incident indicators. Joint Commission International Surabaya, based on the document review, already
2015 stated that measure is a process of collecting has a document listing the incident causes. Infection
and merging data. This process helps to assess the incidents at The Mother and Child Hospital of
level of performance, determine whether corrective Kendangsari MERR Surabaya had three problem
action is needed, and ensure whether root causes from three different factors.
improvements have occurred. At the Mother and
Child Hospital of Kendangsari MERR Surabaya, Explore and identify risk reduction strategies
based on the document review, there were The next step is to identify the improvement
indicators or work targets for the infection insidents steps and risk reduction strategies. After identifying
that occurred, such as the number of infections per the main causes of the incidents, the identification of
month, three months, semester, and year. One improvement measures and risk reduction
example of work targets is the one for surgical site strategies can be done using various techniques to

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 Jurnal Administrasi Kesehatan Indonesia Volume 7 No 1 January-June 2019
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doi: 10.20473/jaki.v7i1.2019.18-24

achieve potential action plans. The Mother and Evaluate the Implementation of Improvement
Child Hospital of Kendangsari MERR Surabaya has Efforts
not implemented risk reduction. Therefore, risk The next stage is done using the data
reduction can be done using one of the methods collected as a part of the measurement. The data
mentioned by the 2015 Joint Commission must be translated into information to make an
International, namely Failure Mode and Effects assessment and draw conclusions about the
Analysis (FMEA). performance of the improvement efforts. This
FMEA is a systematic and prospectively assessment forms a basis for further action taken
proactive method used to identify and understand with the improvement initiatives. Many techniques
the contributing factors involved in the failure of a can be used to assess the data. Most types of
process, system, or method. In addition, this method assessments require comparing data to a reference
can be used as an active tool to improve patient point.
safety and hospital efficiency. The method
determines the vulnerable and critical elements of a Take additional action
system (Shebl, Franklin and Barber, 2012). The team's assessment of the data shows
whether or not the targets have been achieved. This
Formulate improvement actions stage is related to the set targets of the action plan
The measure of success can be determined that has been tested and implemented. If the
from trial activities that are carried out. The Mother objectives are achieved, the team must now focus
and Child Hospital of Kendangsari MERR Surabaya on communication, standardization, and introduction
has not yet identified the measure of its success. of successful improvement initiatives.
The scientific method of Joint Commission
International 2015, such as plan, do, study, act Communicate the results
cycle, can be proposed to find the measure of The RCA results must be communicated to
success. This method allows the team to test how all staff members involved and the management. It
successful changes have been made and whether is very important to build trust and appreciation for
they need to be improved, and other experiments if the team in this process. A table can be made to list
no good results are achieved. the causes, identification of root causes, and
recommendations to everyone. The RCA process is
Evaluate the proposed improvement actions based on Joint Commission International standards,
The evaluation process is done by but there are steps that have not been implemented
comparing plans with internal references, SOPs, by the Mother and Child Hospital of Kendangsari
and external practices and standards to help the MERR Surabaya due to the ommission of other
final action plan executed well. methods, such as fishbone and PDSA. Moreover,
there are limitation of available resources, one of
Design improvements which is that most IPC committee members have
Design improvement is an action plan that not received training about RCA. The committee
identifies the strategies to be implemented in order can work with the team of Patient Safety Quality
to reduce the risk of similar incidents occurring in Control (PSQC) at the hospital for the
the future. The Joint Commission International 2015 implementation of RCA because PSQC team has
mentioned the plan must address five issues about received RCA special training. The following
what, how, when, who and where are the methods are suggested to be applied for the
implementation and evaluation of the effective and implementation of RCA (Brook et al., 2015).
corrective actions. The Mother and Child Hospital of First is Pareto analysis. This is an easy-to-
Kendangsari MERR Surabaya, based on the use technique that helps user choose the most
document review, had the documents of the effective changes to do. The Pareto principle
recommendation forms and the action plans for the mentions the idea of doing 20% of your work can
incidents. generate 80% of your profit in doing the whole job.
Pareto analysis is a formal technique for finding
Ensure the acceptability of the action plan changes that will yield the greatest benefits.
The step is taken to ensure the action plan is Second, Osborn suggests that groups can
acceptable. The document review found that the double their creative results with brainstorming.
Mother and Child Hospital of Kendangsari MERR Brainstorming works by focusing on the problem,
Surabaya has not implemented the step to ensure and subsequently formulate as many solutions as
the acceptance of the action plan. possible and develop them as far as possible. Using
brainstorming refers to the process of generating
Develop Measures of Effectiveness and Ensure new ideas or solving problems so that the goal is to
Their Success identify not only the most obvious root causes, but
If the function is in progress, the team must also the possible underlying problems.
collect data about its performance. The Joint Third is the 5 WHYs. This is the simplest
Commission International 2015 stated that method for structured RCA. This is a method of
measurement is a process of collecting and asking questions which later be used to explore the
combining data to assess the level of performance causes underlying the problem. The investigator
and determine whether further corrective action is continues asking the question 'Why?' until a
needed. Particularly, measurements can be used as meaningful conclusion is reached. General
integral techniques throughout Plan-Do-Study- recommendation is that the investigator asks the
Action (PDSA) cycle. questions at least five times, although sometimes

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