RT Journal Article
SR Electronic
T1 Improving RCA performance: the Cornerstone Award and the power of positive reinforcement
JF BMJ Quality & Safety
JO BMJ Qual Saf
FD BMJ Publishing Group Ltd
SP 974
OP 982
DO 10.1136/bmjqs.2010.049585
VO 20
IS 11
A1 James P Bagian
A1 Beth J King
A1 Peter D Mills
A1 Scott D McKnight
YR 2011
UL http://qualitysafety.bmj.com/content/20/11/974.abstract
AB Background The Veterans Health Administration has had a comprehensive patient safety program since 1999 that includes conducting root cause analysis (RCA) of adverse medical events. Improving the quality and timeliness of the RCAs at the local level has been a continual challenge.Methods We initiated a non-monetary program called the Cornerstone Award into our patient safety reporting system to recognise facilities conducting high-quality and timely RCAs containing deterministic corrective actions that are implemented and evaluated for effectiveness.Results Since the Cornerstone Program began in 2008, the per cent of RCAs completed in a time-critical manner (≤45 days) has increased from an average of 52% pre-Cornerstone to an average of 94% post-Cornerstone. The per cent of action plans with stronger deterministic actions and outcomes has increased from an average of 34% pre-Cornerstone to an average of 70% post-Cornerstone.Discussion 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.