ABSTRACT
This chapter describes standardized work for different RCA roles, including facilitator, Executive Sponsor, Process Owner, directly involved caregivers, physician leader, Subject Matter Experts, and support services.
The Executive Sponsor is responsible for supporting the RCA process and removing barriers as needed. The Process Owner is typically an operational leader with direct accountability for the processes involved in the unintended event. Caregivers directly involved in an unintended event provide critical information. RCAs involving clinicians benefit from the participation of a physician leader, typically a Medical Director, Division Chief, or Medical Staff Officer, who can also serve as a liaison to the clinicians involved in the unintended event. Subject Matter Experts like informaticists, pharmacists, biomedical engineers, and facility engineers provide specific content knowledge.
Implementing standardized work through training, orienting, and coaching RCA team members is an important way to champion effective RCA. Experience shows the most effective form of training is to provide sessions dedicated to defining RCA and the roles of Executive Sponsor, Process Owner, and Subject Matter Expert. The scope of training may span from unintended event identification through action plan completion, or individual elements of the RCA process.
