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Changing Practice

Improving compliance with the C. difficile root cause analysis tool to reduce incidence

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A project to improve the effective application of root cause analysis to reduce incidence



Owen, L. (2009) Improving compliance with the C. difficile root cause analysis tool. Nursing Times; 105: 16, early online publication.

A project to improve the effective application of root cause analysis to reduce rates of Clostridiumdifficile infection. Using a learning intervention and redefining infection-control practices produced better compliance with the root cause analysis tool on six medical elderly wards.

Keywords:Clostridium difficile, Infection control, Root cause analysis

This article has been double-blind peer reviewed 


Liz Owen, BEd, Cert Infection Control, RGN, is infection prevention and control nurse, Hull and East Yorkshire Hospitals NHS Trust.



  • C. difficile is the most important cause of infectious nosocomial diarrhoea in the UK. The NHS Operating Framework for 2008-2009 set a national reduction target of 30%, to be achieved by 2011 (DH, 2007c).
  • Organisations with the greatest success in reducing infections have systems in place to monitor the effectiveness of the clinical process and use compliance and infection data to focus their improvement work more effectively.
  • A root cause analysis tool, when used correctly, can identify any omissions in care or problems with practice that may have contributed to the infection.


In Essential Steps to Safe, Clean Care (Department of Health, 2007a), healthcare-associated infections (HAIs) are defined as infections that are acquired in hospitals or as a result of healthcare interventions. The DH has set measurable targets to achieve reductions in HAIs. The DH (2007b) stated that those organisations which demonstrate the greatest success in reducing infections have instigated systems to monitor the effectiveness of the clinical process. They also understand the benefit of using compliance and infection data to focus their improvement work more effectively.

The Health Protection Agency (HPA) requires mandatory reporting of all patients diagnosed with an MRSA bacteraemia. This includes the completion of a root cause analysis tool (RCA). The RCA’s purpose is to identify any omissions in care or problems with practice that may have contributed to the infection. This allows learning outcomes to be pinpointed and an action plan to be formulated and implemented.

Clostridium difficile is the most important cause of infectious nosocomial diarrhoea in the UK (HPA, 2008). NHS organisations are required to have a policy in place that makes provision for appropriate infection-control procedures (DH, 2006). The NHS Operating Framework for 2008-2009 stipulates a national reduction target for C. difficile infection of 30%, to be achieved by 2011 (DH, 2007c).

In order to comply with the national target it is essential to minimise risk factors associated with C. difficile infection and effectively manage cases when they occur. To meet these standards, a modified RCA tool, based on that used for MRSA bacteraemia, was adopted by the trust. It was hoped that this would enable ward managers and clinicians to review patient care when C. difficile infection was detected and identify any necessary modification to practice, education or training.


RCA project

The C. difficile RCA tool was initially piloted on medical elderly wards before being introduced across the whole trust. During the six-month pilot period, administrative support staff from the infection prevention and control team monitored completion of the tool and contacted any ward which failed to return an RCA – a time-consuming and impractical task trust-wide. It was important that wards took individual ownership and responsibility for completing the tool (DH, 2003).

It seems reasonable that those wards accustomed to using RCA to improve practice, in this case medical elderly wards, would have reduced their infection rates. An examination of the number of patients diagnosed as C difficile-positive during March and April 2008 identified that 21% of all C. difficile infections were acquired on these wards. A comparison of C. difficile infection rates for the same period during 2007 showed that 20% of positive patients were located on medical elderly wards, suggesting the initial introduction of the RCA tool had not had an impact on infection rates.

When the submitted RCAs were analysed, the overall compliance rate across the trust was found to be 42%, with a compliance rate in the original pilot wards of 44%, suggesting that familiarity with the tool had little impact on response rate. The data also suggested a poor response to the use of RCA.

Better compliance would give specific details to individual wards on the main risk factors contributing to patients acquiring C. difficile infection and identify what changes would prevent reoccurrence. Current use of the RCA tool did not appear to be fulfilling these objectives.  

The content of RCA forms submitted in March and April was analysed, which highlighted sections that were poorly completed and which might have presented some difficulty, or which staff perceived as lacking relevance. Demographic details and recording of objective information, such as antibiotic prescribing and appropriate isolation, appeared to be straightforward. Least successfully completed were subjective questions that required reflection on the information collected and making recommendations for future action.

These findings were not surprising given there had been little formal training in completing the RCA, leading to a system of trial and error. Undertaking RCA is deceptively difficult because it is assumed that the skill of critical thinking and problem-solving comes naturally (Garavaglia, 2008).



When data is of poor quality, inaccurate or incomplete, there is a reluctance to use the information because of concerns over reliability (NHS Institute for Innovation and Improvement, 2007). After critically appraising current use of the C. difficile RCA tool, it was apparent that an improvement plan was needed. The project was a vital step in reducing the incidence of healthcare-associated C. difficile in the inpatient population.

The aims of the improvement plan were:

  • To identify why staff compliance with using RCA was low;
  • To gain staff commitment to the principles of RCA, raise understanding of the reasons for completing the tool and increase the perception that RCA can be an aid to improving practice;
  • For clinicians to learn why infections were occurring and use this knowledge to develop robust and practical action plans to reduce rates of C. difficile infection.



It was decided to undertake the project on a number of identified wards. These changes could be adopted more widely if the project proved to be successful. C. difficile is particularly prevalent in the over-65 age group; therefore the six medical elderly wards were identified as units which might benefit from this intervention.

Kotter (1996) stated that one mistake when trying to make any change is failing to engage the participants concerned. One problem that this improvement plan had to overcome was that there had been few organised awareness events, such as publicity road shows or drop-in sessions, to promote the tool’s initial use and ensure staff signed up to its introduction. Despite the increased time commitment, better forward planning would have raised awareness and understanding and staff would have been more conversant with both the theoretical concept and practical application of RCA.

This lack of initial introduction of the RCA may explain some of the present poor compliance. Gladwell (2001) argued that small changes can have dramatic effects. If this theory is correct, then a small intervention to encourage completion of the RCA should have a discernible effect on compliance. It was hoped that targeting the intervention at identified ward managers would be significant enough to achieve a discernible improvement.

A natural reaction to change tends to be to resist (Hiatt, 2006). Even when staff understand the reasons for completing the RCA, they may remain reluctant and need motivation to support the project. Many improvement projects within the NHS have focused on knowledge through education, training and raising awareness, often by using poster campaigns. Shapiro (2003) suggested these interventions might result in short-term improvements but are only sustained when attitudes are altered and staff become committed to the project, are convinced it is relevant and persuaded that it has a real value.



An interview was carried out with senior staff members on each of the participating wards, together with the matron for the unit. The aim was to build a rapport through semi-structured interviews and allow staff, through critical reflection, to consider all aspects of the RCA tool.

Each interview took the format of three parts:

  • A discussion to review the present situation and explain the increasing national-level concern about C. difficile. Current C. difficile infection rates and compliance data were used to outline why improvement was necessary and the benefits of undertaking RCA to gather information which, when used effectively, should result in improved quality of care, cost and time efficiency(Harth, 2007);
  • As a lack of knowledge about C. difficile might contribute to poor compliance with the RCA, a questionnaire was used to identify knowledge levels in staff completing it. This questionnaire had previously been used in a trust-wide audit of clinical staff knowledge about managing C. difficile infection (Madeo et al, 2008). Answers to the questionnaire demonstrated that all respondents appeared to have a good understanding about C. difficile;
  • Respondents were asked to appraise and analyse the RCA tool and openly express their feelings about its completion. They were encouraged to consider practical issues such as clarity of instructions, ease of use and to discuss whether they found any aspects of the tool difficult to undertake. They were asked what they hoped to achieve by using RCA and whether its use encouraged critical reflection about caring for patients with C. difficile infection. Each respondent was asked whether a formal action plan was subsequently developed and shared with ward staff to improve performance. Although some staff initially said they viewed completing the RCA as a compulsory piece of paperwork - necessary because an infection had occurred but with little real benefit - it was hoped that during the course of the interaction some change was made to their original stance.

For the innovation to have a positive outcome, implementing the plan had to involve fostering better communication that was sustained throughout the study period and beyond. Attention was focused on relevant details in a way that ensured knowledge and ability but which also encouraged the use of the RCA tool more confidently and purposefully. The style of the intervention was intended to allow an exchange of information without participants feeling threatened and ensuring they felt able to ask questions. All charge nurses and matrons work to strict local and national targets to reduce infection rates. It was important they realised that, if used effectively, the RCA could be a positive aid in achieving these targets.

Shapiro (2003) highlighted the need for ongoing effort in any improvement project. In addition to setting up the initial intervention, it was equally important to sustain the commitment and active engagement of the respective charge nurses. Good relationships are more significant than the slickest systems and processes (Glanfield, 2003). In order to sustain initial motivation, throughout the period of the project, frequent informal visits were made to all six wards, to raise the profile of the infection prevention and control team and establish the feeling that support was readily accessible and available.



RCA data from the six medical elderly wards submitted during March and April 2008 was used as a comparative baseline against which the impact of the planned intervention could be measured. After implementing the improvement plan, data relating to compliance with the RCA tool was monitored over a comparable two-month period to evaluate the project’s effectiveness. The plan was to feed back these results to individual wards and to relevant audiences such as the charge nurses meeting.

A comparison of the study wards pre and post intervention established that:

  • Compliance with the RCA improved from 44% to 67%;
  • Patients acquiring C. difficile infection on medical elderly wards reduced from 21% of the trust total to 9% (Table 1);
  • Analysis of RCA showed increased quality of data reporting, compared to the baseline period (Table 2).
  • Comparing both compliance with the RCA tool and the rate of C. difficile infection before and after intervention, using a Chi-square test, showed there was a statistical difference in both cases (p<0.001).


Table 1. Comparison of results pre and post intervention



C. difficile patients on non-intervention


C. difficile patients on intervention wardsMedical elderly  C. difficile patients  rate as % of trust totaTrust RCA complianceMedical elderly ward compliance with RCA
Pre intervention (March/April)34921%42%44%

Post intervention




Table 2. Comparison of quality of data reporting on RCA tool pre and post intervention

Data recordedPre intervention (% of forms)Post intervention (% of forms)
Ward cleanliness (including monitoring officer’s score)5050
Hand hygiene (with compliance score)5050

Reflection on practice:

  • Comprehensively completed
  • Completed with some omissions
  • Not completed









Future recommendations:

  •  Satisfactorily completed
  • Some recommendations made
  • Not completed












These results suggest that the trial intervention had improved compliance with undertaking and completing RCA. It could also be postulated that the reduced rates of C. difficile infection are attributed to the increased awareness of C. difficile on the wards that took part in the improvement project. The real test of success will be to monitor whether these initial improvements are sustained.



The goals for our infection prevention and control team now include giving leadership to staff committed to reducing HAI, rather than accepting sole responsibility for lowering infection rates (Murphy, 2002).

To initiate improvement it was necessary to capture the “hearts and minds” attitude of staff completing the tool (Shapiro, 2003). Reflection and action planning underpins the concept of RCA and is crucial for learning and improving patient safety. All respondents stated that this was challenging. The interaction with charge nurses was key to explaining and promoting the use of RCA. The objective was to empower improvement without making staff dependent on the infection prevention and control team.

The plan was to initiate a degree of input that would achieve a measurable impact. Any ongoing intervention had to be sustainable in terms of work and time commitment for the infection prevention and control team. This ensured that if this innovation achieved its aims, it would be possible to spread the project to other wards with high incidence of C. difficile infection.

Central to this work has been good clinical engagement. It was reassuring that staff were receptive to the initial approach made to them. Glanfield (2003) pointed out that any improvement effort will produce additional unanticipated benefits. Even if RCA compliance is not sustained, professional relationships on the study wards have strengthened, with improved attitudes towards infection control. This work demonstrated that achieving improvement is about effective human interaction. This is a positive outcome that the infection prevention and control team has consciously tried to achieve when working with staff on other wards.

Every clinician has the potential to reduce the risk of infection to their patients by complying with evidence-based practice and guidelines. The Saving Lives programme (DH, 2007b) pointed out that safety and reliability are the most important components in quality healthcare. Effective use of the RCA tool is one way to do this.



Healthcare workers must see benefits in directives if they are expected to comply with them. This project demonstrates an early improvement in compliance that suggests engaging with clinicians and explaining the benefits of RCA is recommended.

What remains to be identified is whether this improved compliance can be sustained and, most importantly, whether C. difficile infection be reduced as a result of subsequent system changes.

Practice points

  • Completion of root cause analysis can be deceptively difficult and, without appropriate knowledge and training, compliance with the procedure may be poor.
  • Providing staff with the appropriate skills to carry out root cause analysis improves data and leads to better infection control.
  • Engaging clinical staff is key to both the success of any intervention and to improving compliance with evidence-based practice and guidelines.



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