Table 5:

Key facilitators, barriers and strategies

Category	Description of Facilitators, Barriers/Challenges and Strategies
HFACS-RCA2 System
Usability	RCA team members indicated that the HFACS-RCA2 materials, including the handbook, tools, and templates were well-designed and easy to use. However, they also indicated that some of the tools, such as the interviewing guide, were too generic and needed to be more specific for each individual case. To address this issue, stakeholders tailored the questions within the interviewing guide to make them relevant for the type of event being investigated. Stakeholders also indicated that the hardcopy of the tools were not flexible enough for use during team meetings. As a result, they developed digital versions of the templates in Microsoft Word and Excel to make them more flexible, easier to share, and simpler to archive.
Utility	Stakeholders indicated that the human factors frameworks (e.g., HFACS and HFIX) and their associated tools were appropriate and useful for investigating the types of patient harm events that were occurring within their healthcare system. They also felt that the methods and tools helped them become more efficient in structuring their investigation activities, including interviewing healthcare providers, analyzing data, developing causal factors pathways, creating causal factors statements, and developing recommendations. One of the challenges encountered was determining the best way to synthesize of the information and integrate it into the existing RCA report format. To address this challenge, stakeholders redesigned their RCA report template to make it compatible with the new HFACS-RCA2 system.
Training Curriculum	Stakeholders stated that the training they received was effective, and that the mock interview activities and team-based case study prepared them to perform these activities upon completion of the course. However, they stated that some RCA team members, particularly ad hoc members, could forget some of the material, because several weeks could go by before they participated in an RCA investigation. They also indicated that additional practice and use of some of the tools and techniques were needed to fully understand them. For example, they reported particular difficulty in developing casual and contributing factors (CCF) statements, even after training and practice. To address these challenges, a refresher video was created and an additional 1-hour follow-up training on CCF statements was provided.
Implementation Process
Planning and Preparation	Planning and preparation activities were highlighted by stakeholders as being very important for success. These activities included developing a communication strategy to inform both leaders and staff about the rationale for the change; strategically recruiting safety-focused clinicians to be part of the new RCA program, ensuring everyone was trained, anticipating changes in workload among RCA teams, negotiating changes in roles and responsibilities across the quality and risk management departments, establishing team schedules and team member rotations, and establishing milestones and metrics for success. Challenges included competition for time and resources with other organizational initiatives that were occurring. Aligning the HFACS-RCA2 program with these other initiatives and priorities, to make it a complementary rather than competing effort, was one strategy used to overcome this potential barrier.
Leadership Engagement	Leadership engagement was repeatedly mentioned by stakeholders as being vital to successful implementation. Leadership engagement was instrumental in recruiting clinical RCA team members, helping ensure that interviewees were allotted time away from their clinical duties to participant, and supporting RCA recommendations that required broad systems-level changes. However, a potential challenge was that not all leaders felt equally familiar with how to perform these tasks; consequently, leadership engagement was somewhat variable early in the process. Soliciting regular feedback from leaders, particularly executive sponsors of RCA teams, was a strategy used to identify problems and implement changes to support leaders in their new roles.
Roles and Responsibilities	Having a formal document that clearly described roles and responsibilities of stakeholders involved in the process helped facilitate implementation. In particular, clarity of roles and responsibilities helped RCA facilitators to feel comfortable distributing workload among the team and it helped team members hold each other accountable for doing the work. However, a frequently mentioned challenge was that it took time for RCA team members, managers, and senior leaders to become comfortable in their roles (see Leadership engagement). Occasional updates to the roles and responsibilities document were needed as stakeholders gained more experience with the process, to ensure that expectations for each role were clearly defined.
Management of Change	Mid-level managers played a key role in managing and coordinating change. Through the use of daily huddles, managers were able to guide RCA team facilitators as they shared experiences, challenges, and strategies for utilizing the new RCA system. Managers were able to monitor progress and ensure that actives and strategies for dealing with challenges did not undermine the fidelity of the HFACS-RCA2 approach. One particular challenge encountered by RCA teams was managing workload and completing tasks in the timeframe allotted. Strategies for addressing this challenge included developing detailed agendas each meeting, distributing workload among RCA team members and identifying tasks that could be completed between meetings, rather than during each meeting. As staff rotated on and off RCA teams over the 18 -month study period, another challenge was to ensure that team members were trained and that RCA facilitators possessed the necessary competencies to be effective team leaders. To address these challenges regular training sessions were conducted and new RCA facilitators shadowed experienced facilitators prior to leading their own team.