The Department of Health & Human Services has developed training and e-learning packages to help Victorian health services and their staff with the principles and processes of clinical risk management.
Root cause analysis (RCA) training is conducted through workshops and virtual refresher meetings.
Training in the Victorian Health Incident Management System (VHIMS), open disclosure and in-depth case review are undertaken on-line through three e-learning packages.
e-Learning packages
There are three e-learning packages that can be completed individually. However, it is strongly recommended that they be completed in sequential order.
Successful completion of all three e-learning packages is a prerequisite for nomination for RCA training.
Package 1: VHIMS e-learning
This e-learning package provides an overview of generic incident management principles and processes as they apply in the Victorian context. The education package comprises:
- definitions
- general aims of incident reporting
- seven steps to effective incident management
- incident severity rating
- incident classification
- case studies
- quiz and certificate upon completion.
Package 2: Open disclosure e-learning
This e-learning package provides an overview designed to increase awareness of open disclosure in healthcare. The education package comprises:
- general principles of open disclosure
- open disclosure procedure
- open disclosure process
- introduction to ‘just culture’
- relationship to the incident management process
- case studies
- quiz and certificate upon completion.
Package 3: In-depth case review e-learning
This e-learning package provides an overview of in-depth case review. The education package comprises:
- Module 1: Human and system errors
- Module 2: Incident response
- Module 3: Incident analysis
- Module 4: Recommendations
- quiz and certificate upon completion of each of the separate modules.
Root cause analysis training
The root cause analysis (RCA) methodology is not designed to investigate every incident or event. The incident severity rating guides the level of investigation, with the exception of events that reflect national sentinel event definition.
In most instances a local investigation and aggregate review, or an in-depth case review is more appropriate. Staff should complete incident management training appropriate to their role in these reviews.
The RCA workshops are for staff directly involved in facilitating a root cause analysis. They provide an overview of the process, in particular:
- verifying and defining the problem
- commissioning an RCA investigation
- forming the RCA team
- gathering information
- mapping and identifying critical events
- analysing and identifying root causes
- identifying solutions
- writing root cause statements
- developing, documenting and presenting recommendations.
See 2018 RCA training dates.
Prerequisite
No fees are charged for the root cause analysis workshops but in order to attend training, staff members must:
- understand the seven steps in effective incident management and how the incident severity rating guides the level of investigation
- complete all three e-learning packages - VHIMS, open disclosure and in-depth case review.
Virtual meetings
The workshops can be followed up with virtual refresher meetings. They cover the cause and effect concepts, writing causal statements and recommendations. These meetings repeat the material presented at the workshops.