Aiming for Improvement Finding the Root Cause Anne Hernandez, QIO Deputy Director Nancy Fendler, QIO Quality Advisor K

1. Aiming for Improvement Finding the Root Cause Anne Hernandez, QIO Deputy Director Nancy Fendler, QIO Quality Advisor Kelley Dotson, GHA August 29, 2012

2. Objectives • Explain the basics of Root Cause Analysis (RCA) • Discuss  methods to simplify the process • Use the RCA for quality improvement

3. Root Cause Analysis (RCA) • Proactive • Customer focused • Involves employees • Uses knowledge and data

4. 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.

5. 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

6. 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.

7. 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.

8. 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

9. 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?

10. 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

11. 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

12. Who? • You! • The “right people” • The voice of the customer • Teams and leaders

13. What? • A tool – for working with ideas (hunches, theories, gut feelings) • A picture of the system elements • May identify what contributes to a problem

14. When? Act Plan Study Do • Do you need to know the root cause? • Are there ideas or opinions about the cause? • Do you want to make a change?

15. Where? • In your home • In your workplace • On the walls – make it visible!

16. Why? “ • You did then what you knew how to do. • And when you knew better, • You did better. ” ~ Maya Angelo

17. How? • Identify a clear problem statement and record it. This is critical. • Identify the major cause categories and connect the causes to the fishbone.

18. How? • Brainstorm the causes • As generated on the tool or on a list • Dig deep – a cause is just the start • Put in the appropriate categories • Test for root cause • Look for repeats • Select the causes • Validate

19. Real Life Example • http://my.brainshark.com/Tim-Conway-and-Harvey-Korman-The-Dentist-562037674

20. 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

22. 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

24. C. Hospitalization unnecessary C.2 Direct admission C.1 Admission via ED C.2.1 Admission guidelines/ recognized practices not followed C.2.2 “Defensive” admission C.2.3 Didn’t want to see/treat C.2.4 Social admissions C.2.5 To satisfy reimbursement requirements C.2.2.1 Incomplete patient information C.2.2.2 Incomplete information about HHA care resources C.2.2.3 Other defensive admissions and C.1.1 Patient presented to ED C.1.2 Unnecessarily admitted from ED C.1.2.2 “Defensive” admission C.1.2.3 Social admissions C.1.2.4 To satisfy reimbursement requirements C.1.2.1 Admission guidelines/ recognized practices not followed C.1.1.1 ED visit necessary C.1.1.2 ED visit unnecessary … 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

25. “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.

26. Ask 5 Whys 1) Why? 2) Why? 3) Why? 4) Why? 5) Why?

27. 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 • WHY? No wound consult completed • WHY? WOCN not notified • WHY? Patient transferred from ICU to Med/Surg unit on Saturday and order did not get entered • WHY? Med/Surg Unit Secretary thought ICU had completed consult request • 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!

28. “5 Whys” Example

29. “5 Whys” Example (cont’d)

30. 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

31. Cause and Effect Diagram Policies People Environment Equipment/Supplies

34. Process Mapping Clarify specific roles and contributions of those involved in the process. • Observe discharge and admission processes directly, interview process owners, and map the processes. • Elicit staff perceptions about where communication issues and gaps may occur.

35. Using RCA to Drive Intervention Selection –Good Example

36. Lunch Time See you back at12:15 p.m.

37. Practical Examples • Pressure Ulcer Rate • Readmission Rate • Med Rec • Falls • VTE

38. 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!

39. 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…

40. Using RCA for Quality Improvement Focus on the most important targets for improvement: • Knowledge • Systems • Behaviors

41. 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.

42. Using RCA for Quality Improvement • Identify what needs to improve • Involve others • Improve it • Plan for R+ and celebration

43. Next Steps • OPTIONS • What would be most effective? • SOLUTION • Don’t jump to this too soon • LIST • Root causes

44. Action Plan WHAT WHO WHEN

45. Action Plan

46. Using RCA for Quality Improvement • Monitor • Evaluate • Improvement seen? • Further improvement • Adopt • Adapt • Abandon • Tell the story Continuous

47. Content Experts = Complete RCA “Rocket science is helpful, but not required.”

48. 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.

49. Root Cause Analysis “Oh, I’ve got one last question.” ~ Columbo • Continue to learn • Teach others • Improve your work • Share your story

50. 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 Let us know how we can help you with your next steps…