Quality Priority:

To increase the number of colleagues trained in Root Cause Analysis and Human Factors.

Current Situation:

Experts in the field of organisational safety culture suggest that 70% of incidents reported should be near miss or no harm. Locala colleagues consistently report above this target, demonstrating that they feel able to report all incidents. The true value in reporting incidents however is in gaining learning from them to prevent them happening again and this can only be done by undertaking thorough investigations with an understanding of why incidents happen. Although Locala has an excellent reporting culture, the way in which learning is shared and understood could be improved.

Why is it a priority?

Root cause analysis is a collective term that describes a wide range of approaches, tools, and techniques used to uncover causes of problems.  It is an important skill for those undertaking any type of investigation. Having a deeper understanding of the techniques will ensure colleagues are able to fully investigate and identify areas for learning to improve care within their teams.

The principles and practices of Human Factors focus on optimising human performance through better understanding the behaviour of individuals, their interactions with each other and with their environment. By acknowledging human limitations, Human Factors offers ways to minimise and mitigate human frailties, so reducing error. The system-wide adoption of these concepts offers a unique opportunity to support cultural change and empower the providers of NHS services to put patient safety and clinical excellence at its heart.

Combining the two approaches will lead to a greater understanding of the causes of incidents and complaints that occur and will also mean Locala is truly able to demonstrate learning.

How will we achieve it?

There are some very credible, free courses available.  The level of training colleagues require will depend on the level of involvement and their role within the organisation.  The Quality team will work closely with the Workforce team to identify those to be trained and explore the best ways to do this. 


We will also explore ways in which the learning can be captured and shared more effectively.