This weeks Nursing Times includes an article by Liz Owen 'Improving compliance with the C. difficile root cause analysis tool' (2009). The piece includes a section that highlights* the importance of reflection, which together with action planning underpins the concept of root cause analysis (p.16).
There are three references in particular cited: Murphy (2002) in relation to the infection and prevention team giving leadership to staff committed to reducing health care associated infections (HCAI) rather than accepting sole responsibility for HCAI. This also entails capturing the 'hearts and minds' of staff (Shapiro, 2003) completing the root cause analysis tool (p.16). Amongst many interesting points - it was found that there were unexpected benefits too (Glanfield, 2003) notably - strengthened relationships and improved attitudes.
This reminds me of affordances in human-machine interfaces and the use of technology more generally. As Owen and others show whatever we call these unexpected outcomes they are by definition unexpected, or not readily accessible to our initial perception and reasoning. Owen found that clinical engagement and leadership proved central in this project. Is there a way to foresee more of the 'unexpected' whether barriers or benefits?
Before being able to engage with others we need to be aware and able to -
A coherent team with the inevitable chaotic-creative outliers that (just 1 or 2....) personalities bring might just help us see around the corners - an additional key asset to safety...
Murphy, D.M. (2002) From expert data collectors to interventionists: Changing the focus for infection control. American Journal of Infection Control; 30: 120-132.
Shapiro, A. (2003) Creating Contagious Commitment. Hillsborough, NC: Strategy Perspective.
Glanfield, P. (2003) Towards sustainable change and improvement. In: Pickering, S.P. (ed) Clinical Governance and Best Value. London: Churchill Livingstone.
Owen, L. (2009) Improving compliance with the C. difficile root cause analysis tool. Nursing Times; 105: 16, early online publication.
*even if that is just a subtitle?