Root Cause Analysis (RCA) Getting to the Root of the Problem

Root Cause Analysis (RCA)

DRIVING IMPROVEMENT

The focus is on three critical

aims to make care better for everyone:

– Better patient care

– Better population health

– Lower healthcare costs through

THE PURPOSE OF

ROOT CAUSE ANALYSIS (RCA)

•

 

Identify the “root” cause of readmissions

at your hospital

•

 

Identify patterns of readmissions specific

to your community and its providers

•

 

Use RCA results to guide targeting

OVERALL PROCESS

• Collect data

• Analyze data

• Develop and evaluate corrective actions

using Plan, Do, Study, Act (PDSA) cycle

• Implement successful corrective

VARIETY OF RCA TOOLS

•  Patient/family interviews

•  Care coordinator interviews

•  Medical record reviews

•  Process mapping

•  Cause-and-effect diagrams

•  “The 5 Whys Process”

PATIENT/FAMILY INTERVIEWS

•

 

Semi-structured telephone or

face-to-face interviews with patients who were

readmitted

•

 

Helps to identify opportunities for

improvement from the patient’s

perspective

CARE COORDINATOR INTERVIEWS

•  Conduct individual and/or group interviews

with care coordinators

•  Identify patterns, trends, and opportunities

for improvement from the staff member’s perspective

•  Formulate groups across settings or within

provider teams, organizations, or specialties

MEDICAL RECORD REVIEWS

•

 

Review randomly sampled hospital

discharges and 30-day readmissions

•

 

Common finding:

– Patient education is completed and

documented, but patients need more in-depth understanding to be compliant

PROCESS MAPPING

9

Clarify specific roles and contributions of those

involved in the process

•  Observe discharge and admission processes directly

•  Interview process owners

•  Map the processes

Obtain staff perceptions about where

COMMON PROCESS MAPPING SYMBOLS/SHAPES

CAUSE-AND-EFFECT DIAGRAM (FISHBONE DIAGRAM)

•

 

Visually illustrates potential causes of

“THE 5 WHYS PROCESS”

•  This is simple and easy to complete without

statistical analysis

•  Start with asking why readmissions occur at

your hospital and record the answer. If the

answer provided does not directly identify the root cause of your readmission problem, ask why again and record the answer

•  Continue this process until your team agrees

the problem’s root cause has been identified-usually takes 3-5 cycles

“THE 5 WHYS” EXAMPLE

Why are so many Medicare beneficiaries

with heart failure being readmitted to

our hospital?

•  Because they do not

understand or remember the red flags related to their condition after discharge

Why do they not understand the

red flags?

•  They do not

have the correct documentation or reminder

“THE 5 WHYS” EXAMPLE (cont’d)

Why do they not have the proper

documentation or reminders?

•  Because they did not receive a

Personal Health Record (PHR) or red flag magnet with

documentation of these red flags upon discharge

Why did they not receive the PHR

or magnet?

•  Distribution of

these materials is not part of the current discharge process

Results from Previous

Care Transition RCAs

“

Rocket science

is helpful, but

not required.”

RESULTS FROM PREVIOUS CARE

TRANSITION RCAs (cont’d)

•  RCAs revealed remarkably consistent

results

•  Patients experienced readmissions

because of:

–  Unmanaged worsening of their conditions

–  The use of suboptimal medication regimens

–  Returning to emergency departments instead of accessing a different type of medical service

INTERVENTIONS TO IMPROVE

CARE TRANSITIONS

•  Care Transitions Intervention℠

•  Transitional Care Model

•  INTERACT II

•  HHQI Best Practice Intervention Packages

•  Project Boost

•  Bridge model

•  Project RED

•  GRACE Model

SYSTEM-LEVEL DRIVERS OF

READMISSION

Poor provider-patient interface

Medication management, no effective patient engagement strategies, unreliable follow-up

Unreliable system support

Lack of standard and known processes Unreliable information transfer

Unsupported patient activation during transfers

No community

infrastructure for

BUILDING A COMMUNITY-BASED PROGRAM Root Cause Analysis ID Driver of Readmission Select Intervention Measure Intervention Did Intervention Address Driver

INTERVENTIONS AND DRIVERS

Intervention Patient Activation Standard Process Information Transfer

Care Transitions Intervention℠ •••••• •

Transitional Care Model _{• ••• •••••}

INTERACT II •• ••

HHQI Best Practices •• •• ••

Project Boost _{•••••• •••}

Bridge Model _{••• •••}

Project RED _{•••••• •••}

GRACE Model _{••• •••}

USING RCA TO DRIVE INTERVENTION

SELECTION—GOOD EXAMPLE

RCA Technique: Process Mapping Hospital Discharge Key Findings: No standard process, discharge is chaotic, varies based on staff

Intervention Selection: Project RED Intervention improves hospital discharge process Intervention directly

addresses root cause identified

USING RCA TO DRIVE INTERVENTION

SELECTION—POOR EXAMPLE

RCA Technique: Process Mapping Hospital Discharge Key Findings: No standard process, discharge is chaotic, varies based on staff

Intervention Selection: Care Transitions Intervention℠ Intervention improves patient activation and engagement Intervention does

not address root cause identified

USING RCA TO DRIVE INTERVENTION

SELECTION—GOOD EXAMPLE

RCA Technique: Interview all patients who

are currently in the hospital for a 30-day

readmission

Key Findings: (1) Patients did not understand/did not correctly take

medications, and (2) Patient condition worsened; unsure of what to do, so patients called 911

or came to ED

Intervention Selection: Care

Transitions Intervention℠

Intervention improves patient activation and engagement— addresses four pillars (PHR,

red flags, medication management, and follow-up)

Intervention directly addresses root cause

identified

THREE BASIC SYSTEM GAPS

•

 

Lack of engagement or activation of

patients and families

•

 

Lack of standard processes among

providers for transferring patients

– No medical responsibility

•

 

Ineffective or unreliable sharing of

RCA CONCLUSION

•  Many of the evidence-based interventions to

improve transitional care are directed at one or more of these gaps but require cooperative activity by more than one provider

•  All communities must build cross-setting or

multi-provider relationships to deploy,

measure, and revise implementation strategies

•  Community building is the necessary

COMMUNITY BASED CARE TRANSITIONS PROGRAM (CCTP) APPLICATION

•

 

Describe the results of the RCA that was

performed

•

 

Describe how the results informed the

selection of the proposed intervention and

target population

COMMON APPLICATION ERRORS

•

 

The community-specific RCA is missing

•

 

The community-specific RCA is present

but not explicitly tied to the methodology

for targeting high-risk beneficiaries and

the proposed interventions

•  CCTP Application Link

NATIONAL COORDINATING CENTER

QUESTIONS/DISCUSSION

Betty DeBlasio RN QI Specialist Qsource [email protected] 615.574.7200

Material prepared by Qsource, the Medicare Quality Improvement Organization (QIO) for Tennessee, under contract with the Centers for Medicare & Medicaid Services (CMS),

an agency of the U.S. Department of Health and Human Services. Contents presented do not necessarily reflect CMS policy. Publication No. 12.CPC.01.009