Root Cause Analysis (RCA) in ICPCA

1. Root Cause Analysis in Care Transitions: Chart Review ToolsTom Ventura, MS, MSPHtventura@cfmc.org Colorado Foundation for Medical Carewww.cfmc.org/integratingcare March 22nd, 2012 This material was prepared by CFMC PM-4010-094 CO 2012, the Medicare Quality Improvement Organization for Colorado 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.

2. Root Cause Analysis (RCA) in ICPCA • Identify community-specific drivers/root causes of readmission • Customize the selection and targeting of interventions • Expressly part of Aim strategy • “Identify service patterns associated with readmission”

3. RCA in ICPCA

4. RCA in CCTP Application requirements “Describe the results of the RCA that was performed.” “Describe how the results informed the selection of the proposed intervention and target population.” “Describe your implementation strategy.”

5. 9th SOW RCA: specific findings Reasons for experiencing readmission Unmanaged worsening of condition Use of suboptimal medication regimens Return to emergency department instead of accessing a different type of medical service

6. 9th SOW RCA: initiative-level “Readmissions are a community problem.” Poor patient-provider interface Medication mis-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 achieving common goals

7. RCA methods • Medical record review • Interview • Patient/family • Provider/care coordinator • Focus group • Process mapping • Cause-and-effect diagram • 5 Whys

8. Medical record review • Review charts among a sample of patients who experienced readmission. • Sample size: small • Readmission and index admission charts • Structured review protocol • Narrative reflection • Types of information extracted • Commonalities, themes • Patient characteristics, behaviors • Provider and system factors • Underlying causes • Leverage points for intervention

9. Readmission-specific tools • NJ: Healthcare Quality Strategies, Inc. • 30-day Readmission Chart Review Form • PA: Quality Insights of Pennsylvania • Readmission Review Form • IHI: STAAR Initiative • Readmissions Diagnostic Worksheet

10. HQSI (NJ) tool • Claims-based fields • Diagnoses, hospitalization dates (LOS) • Readmission chart review (21 items) • MD office; ED visit; observation stays • Documentation • Reasons for readmission (i.e., patient/family, physician/nurse) • PHR, discharge plan • Discharge disposition • Patient education, instructions • Planned versus unplanned readmission • Open reflection • Potential hospital problems • Missed opportunities

11. HQSI (NJ) tool: comments Comments from New Jersey team: • Despite everyone’s best efforts, documentation can still be lacking. • Requires clarification • May be unreliable (e.g., patient education) • Recommendations • Admission chart review to fill in holes • Patient/family interviews in conjunction with chart review • Pilot implementation of tool • Dial in setting-specific issues • Prompt a quality improvement process (improve documentation) • Caveat: targeted heart failure patients

12. Quality Insights (PA): 1-pager • Section 1 • Dates, diagnoses, discharge disposition • Planned vs. unplanned readmission • Section 2 (13 items) • Post-discharge level of care • Physician follow-up • Referrals for home health, hospice, community resources (e.g. AAA) • Medication Reconciliation • Symptoms • Present on first admission • Discharge plan • Patient education • Admission • Unforeseen; avoidable; relation to first admission

13. Quality Insights (PA): 2-pager • Index admission • Dates, diagnoses, discharge disposition • Planned vs. unplanned • Readmission • Dates; planned vs. unplanned • Potential readmission factors (10 domains, 27 items) • Downstream provider issue • Patient/caregiver education • Patient activation • Medication management • Transitional care planning (services offered) • Discharge instructions • End of life • Discharge disposition • Unstable condition at discharge • Recurring possible triggers for readmission

14. Quality Insights (PA): comments Comments from the Pennsylvania team: • Initial findings based on ~60 charts • 15-20 charts reviewed per month, over 3 months • Process • Review readmission data submitted by providers • Generate a trending report and list of patients • Feedback to hospital • Random chart reviews with narrative • Issues • Get consistent information from reviewers across levels of clinical expertise • Results • Sustainable • High satisfaction, despite initial resistance • 10 domains (readmission risk factors) • Evolution • 7-day readmission review • Cross-setting chart review (downstream providers)

15. IHI STAAR worksheets • In-depth review of 5 most recent readmissions • Identify opportunities for improvement • Chart review and interview components • Worksheet A: chart review • Details and documentation (9 items) • Reflective summary (7 prompts) • Worksheet B: interviews • Structured interviews (9 items): patient, family, and care team • Reflective summary (8 prompts) • Reference list of typical failures

16. IHI STAAR: Worksheet A Details and documentation • Days between discharge and readmission • Follow-up physician visit scheduled prior to discharge • Patient attended office visit • Urgent clinic/ED visit before readmission • Functional status on discharge • Clear discharge plan • Teach-back • Reasons for readmission • Social conditions contributing to readmission

17. IHI STAAR: Worksheet B Structured interviews • Patient/family • Reasons for symptom worsening and readmission • Physician follow up • Barriers • Medications • Behaviors • Barriers to adherence • Nutrition • Care team • Reason for readmission • Reflection on patient circumstances contributing to readmission

18. IHI STAAR: reflective summary Worksheets A and B • What did you learn? • Most common failures? (Worksheet B only) • Trends or themes • What surprised you? • New questions • What are you curious about? • What to do next? • Challenged assumptions about readmissions

19. RCA challenges • Don’t over-study. • Elegant, comprehensive demonstrations of the problem are not required. • Cumbersome, technically-detailed exercises enable you to avoid moving forward. • Remember these guiding principles. • The purpose is to inform the PDSA cycle, test interventions, and drive action on a larger scale. • Get just enough information to generate a reasonable set of priority actions.

20. RCA resources • ICPCA Toolkit (NJ/PA tools) • http://www.cfmc.org/integratingcare/toolkit_rca.htm • IHI STAAR Readmissions Diagnostic Worksheet • http://www.ihi.org/knowledge/Pages/Tools/ReadmissionsDiagnosticWorksheet.aspx

21. Thank you! ICPCA National Coordinating Center • www.cfmc.org/integratingcare • Tom Ventura (tventura@cfmc.org)