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)
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Proactive
►
Customer focused
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Involves employees
►
Uses knowledge and data
2
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
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►
►
►
►
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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
►
►
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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
– What actions to implement
– Select solutions
– Who to implement
– Implement actions
– 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.2 Direct admission
C.1 Admission via ED
C.2.1 Admission
guidelines/
recognized practices
not followed
C.2.2.1 Incomplete
patient information
and
C.1.1 Patient
presented to ED
C.2.3 Didn’t want
to see/treat
C.2.2.2 Incomplete
information about
HHA care resources
C.2.4 Social
admissions
C.2.5 To satisfy
reimbursement
requirements
C.2.2.3 Other
defensive admissions
C.1.2 Unnecessarily
admitted from ED
C.1.2.1 Admission
guidelines/ recognized
practices not followed
C.1.1.1 ED visit
necessary
C.2.2 “Defensive”
admission
C.1.1.2 ED visit
unnecessary …
C.1.2.2 “Defensive”
admission
C.1.2.2.1 Incomplete
patient information
C.1.2.3 Social
admissions
C.1.2.2.2 Incomplete
information about HHA
care resources
C.1.2.4 To satisfy
reimbursement
requirements
C.1.2.2.3 Other
defensive admissions
“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
Always get
to the ROOT
of the
problem
before you
start to fix a
problem!
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
“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
systems in
place.
“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.
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
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.
Using RCA to Drive Intervention Selection –
Good Example
RCA Technique:
Process Mapping
Hospital Discharge
Intervention directly
addresses root cause
identified
Intervention
improves hospital
discharge process
Key Findings: No
standard process,
discharge is chaotic,
varies based on staff
Intervention
Selection: Project RED
Lunch Time
See you back at
12:15 p.m.
Practical Examples
►
Pressure Ulcer
Rate
►
Readmission
Rate
►
Med Rec
►
Falls
►
VTE
Using RCA for Quality Improvement
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Use of tool is just the first step
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Collect data on key process
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Uncover the patterns
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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
OPTIONS
LIST
 Root
causes
 What would
be most
effective?
SOLUTION
 Don’t jump
to this too
soon
Action Plan
WHO
WHAT
WHEN
Action Plan
Action Steps
What Will Be
Done?
Responsibilities
Who Will Do
It?
Timeline
By When? A.
(Day/
B.
Month)
Resources
Resources Available
Resources Needed
(financial, human,
time & other)
Potential Barriers
Communications Plan
A. What individuals or
Who is involved?
organizations might
What methods?
resist?
How often?
B. How?
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
►
Continuous
Tell the story
45
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 multiprovider 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 how
we 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