Aiming for Improvement

Finding the Root Cause

Anne Hernandez, QIO Deputy Director

Nancy Fendler, QIO Quality Advisor

Kelley Dotson, GHA

August 29, 2012

Objectives

► Explain the basics of Root Cause Analysis (RCA)

► Discuss  methods to simplify the process► Use the RCA for quality improvement

Root Cause Analysis (RCA)

► Proactive

► Customer focused

► Involves employees

► Uses knowledge and data

3

Background

► When performing root cause analysis, it is necessary to look at more than just the immediately visible cause, which is often the proximate cause.

► There are underlying organizational causes that are more difficult to see, however. They may contribute significantly to the undesired outcome and, if not corrected, will continue to create similar types of problems.

Definitions

Root Cause Analysis (RCA)► A structured evaluation method that identifies the root

causes for an undesired outcome and the actions adequate to prevent recurrence. Root cause analysis should continue until organizational factors have been identified, or until data are exhausted.

► RCA is a method that helps professionals determine:

What happened How it happened Why it happened

► Allows learning from past problems, failures and accidents

Purpose of RCA

► The objective of RCA is to identify “root cause(s)” so that these latent failures may be eliminated or modified and future occurrences of similar problems or mishaps may be prevented.

► Analysis Pitfall: If root cause analysis is not performed, and the analyst only identifies and fixes the proximate causes, then the underlying causes may continue to produce similar problems or mishaps in the same or related areas.

Overview of Steps in an RCA

► Clearly define the undesired outcome.► Gather data, including a list of all potential

causes.► Determine your method of root cause analysis.► Continue asking “why” to identify root causes.► Check your logic and eliminate items that are

not causes.► Generate solutions that address both proximate

causes and root causes.

Root Cause Analysis - Steps

1. Clearly define the undesirable outcome

► Describe the undesired outcome

► Examples– pressure ulcer rate increased– patient fell in ED and broke his arm– readmission rate significantly increased

Root Cause Analysis - Steps

2. Gather data

► Identify facts surrounding the undesired outcome.► When did the undesired outcome occur?► Where did it occur?► What conditions were present prior to its occurrence?► What controls or barriers could have prevented its

occurrence but did not?► What are all the potential causes?► What actions can prevent recurrence?

Root Cause Analysis - Steps

3. Select the best RCA Tool for your Undesired Outcome

► 5 WHYs Analysis► FISHBONE► Pareto Analysis► Process Mapping► FMEA► Fault Tree Analysis

Root Cause Analysis - Steps

4. Continue to ask “why” until you have reached:

► THE Root cause(s)

► A problem that is not correctable

► Insufficient data to continue

Who?

► You!► The “right people”► The voice of the customer► Teams and leaders

Teams And Leaders

– Empowered

– Select solutions

– Implement actions

– What actions to implement

– Who to implement

– When to hand off

What?

► A tool – for working with ideas (hunches, theories, gut feelings)

► A picture of the system elements

► May identify what contributes to a problem

When?

► Do you need to know the root cause?

► Are there ideas or opinions about the cause?

► Do you want to make a change?

Act Plan

Study Do

Where?

► In your home

► In your workplace

► On the walls – make it visible!

Why?

You did then what you knew how to do.

And when you knew better, You did better.

“

”~ Maya Angelo

How?

1. Identify a clear problem statement and record it. This is critical.

2. Identify the major cause categories and connect the causes to the fishbone.

How?

3. Brainstorm the causes

– As generated on the tool or on a list

– Dig deep – a cause is just the start

4. Put in the appropriate categories

5. Test for root cause

– Look for repeats

– Select the causes

– Validate

Real Life Example

► http://my.brainshark.com/Tim-Conway-and-Harvey-Korman-The-Dentist-562037674

RCA Methods

Select a tool for construction:

► Pareto Analysis = Use when multiple potential causes have been identified

► FMEA = Failure mode and effects analysis

► Fault Tree Analysis = Risk or Safety Analysis

► 5 WHYs Analysis = Dispersion analysis

► FISHBONE = Process classification

► Process Mapping = Major processes in the system

Pareto Chart – 80/20 Rule

► A few causes create most of the effects.

► Bar Graph– Most to least– Focuses

attention on best opportunity for improvement

C. Hospitalization unnecessary

C.1.1 Patient presented to ED

C.2 Direct admission

C.2.1 Admission guidelines/

recognized practices not followed

C.2.3 Didn’t want to see/treat

C.2.2 “Defensive” admission

C.2.4 Social admissions

C.2.2.1 Incomplete patient information

C.2.2.2 Incomplete information about HHA care resources

C.2.2.3 Other defensive admissions

C.1 Admission via ED

C.1.1.2 ED visit unnecessary …

C.1.1.1 ED visit necessary

C.1.2 Unnecessarily admitted from ED

C.1.2.1 Admission guidelines/ recognized practices not followed

C.1.2.2 “Defensive” admission

C.1.2.3 Social admissions

C.1.2.2.1 Incomplete patient information

C.1.2.2.2 Incomplete information about HHA

care resources

C.1.2.2.3 Other defensive admissions

and

C.2.5 To satisfy reimbursement requirements

C.1.2.4 To satisfy reimbursement requirements

“5 Whys”

► 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 readmissions problem, ask why again and record the answer.

► Continue this process until your team agrees the problem’s root cause has been identified.

Ask 5 Whys

1) Why?

2) Why?

3) Why?

4) Why?

5) Why?

Be an investigator…

Ask Why 5 Times

Find out what the actual cause of a problem is by asking WHY till you get to the REAL root of the problem!

Example: No Wound Assessment documented on patient admitted to ICU with a Stage III PU

1. WHY? No wound consult completed

2. WHY? WOCN not notified

3. WHY? Patient transferred from ICU to Med/Surg unit on Saturday and order did not get entered

4. WHY? Med/Surg Unit Secretary thought ICU had completed consult request

5. WHY? The ICU Unit Secretary is really dependable and she didn’t look at that order to be sure it had been entered into order entry system

Always get to the ROOT of the problem before you start to fix a problem!

“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?

“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?

Cause-and-Effect Diagram(Fishbone Diagram)

► Visually illustrates potential causes of high readmissions

Identify the problem on nose of the fish.

Diagonal bones:

• Manpower (Personnel)• Materials/Equipment• Methods/Procedures• Environment• Management/Policies

Cause and Effect Diagram

Policies

Environment

People

Equipment/Supplies

Process Mapping

► Observe discharge and admission processes directly, interview process owners, and map the processes.

► Elicit staff perceptions about where communication issues and gaps may occur.

Clarify specific rolesand contributions of those involved in the process.

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 –Good Example

Lunch Time

See you back at12:15 p.m.

Practical Examples

► Pressure Ulcer Rate

► Readmission Rate

► Med Rec

► Falls

► VTE

Using RCA for Quality Improvement

► Use of tool is just the first step

► Collect data on key process

► Uncover the patterns

► Get a consensus on the RCA!

Scenarios with Practical Application

► RCA Process Handout► Exercise Instructions► Select the Topic You would like to focus on:

– Falls– Hospital Readmissions– Medication Reconciliation

► Each “team” will walk through each type of RCA on their selected topic– Fishbone– Process Map– 5 Whys…

Using RCA for Quality Improvement

Focus on the most important targets for improvement:

► Knowledge

► Systems

► Behaviors

Develop Corrective Actions and a Follow-up

► Determine workable solutions for the root causes.

► Re-visit any “quick fix” solutions that were put in place.

► Use other PI tools to assist.

Using RCA for Quality Improvement

► Identify what needs to improve► Involve others► Improve it► Plan for R+ and celebration

Next Steps

LISTRoot

causes

OPTIONS

What would be most effective?

SOLUTION

Don’t jump to this too soon

WHO WHAT WHEN

Action Plan

Action Plan

Action StepsWhat Will Be

Done?

Responsibil-ities

Who Will Do It?

TimelineBy When?

(Day/ Month)

ResourcesA. Resources AvailableB. Resources Needed

(financial, human, time & other)

Potential BarriersA. What individuals or

organizations might resist?

B. How?

Communications PlanWho is involved? What methods?

How often?

Step 1: A.B.

A.B.

Step 2: A.B.

A.B.

Step 3: A.B.

A.B.

Using RCA for Quality Improvement

► Monitor► Evaluate► Improvement seen?► Further improvement

– Adopt– Adapt– Abandon

► Tell the story

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Continuous

Content Experts = Complete RCA

“Rocket science is helpful, but not

required.”

RCA Conclusion

► RCAs revealed remarkably consistent results.► 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 groundwork to enable improvement.

Root Cause Analysis

“Oh, I’ve got one last question.”

~ Columbo

► Continue to learn► Teach others ► Improve your work► Share your story

Let us know howwe can help you with

your next steps…

This material was prepared by Alliant | GMCF, the Medicare Quality Improvement Organization for Georgia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 10SOW-GA-IIPC-12-208