Root Cause Analysis in Care
Transitions: Chart Review Tools
Tom Ventura, MS, MSPH
tventura@cfmc.org
Colorado Foundation for Medical Care
www.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.
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”
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RCA in ICPCA
Perform Root Cause
Analysis
Determine
Effectiveness
Track Process
and Outcome
Data
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Identify Driver
of
Readmissions
Select and
Implement
Intervention
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.”
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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
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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
RCA methods
• Medical record review
• Interview
– Patient/family
– Provider/care coordinator
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Focus group
Process mapping
Cause-and-effect diagram
5 Whys
Medical record review
• Review charts among a sample of patients who
experienced readmission.
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Sample size: small
Readmission and index admission charts
Structured review protocol
Narrative reflection
Types of information extracted
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Commonalities, themes
Patient characteristics, behaviors
Provider and system factors
Underlying causes
Leverage points for intervention
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
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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
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Discharge disposition
Patient education, instructions
Planned versus unplanned readmission
Open reflection
• Potential hospital problems
• Missed opportunities
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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
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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
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Quality Insights (PA): 2-pager
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Index admission
– Dates, diagnoses, discharge disposition
– Planned vs. unplanned
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Readmission
– Dates; planned vs. unplanned
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Potential readmission factors (10 domains, 27 items)
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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
Quality Insights (PA): comments
Comments from the Pennsylvania team:
• Initial findings based on ~60 charts
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Process
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Sustainable
High satisfaction, despite initial resistance
10 domains (readmission risk factors)
Evolution
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Get consistent information from reviewers across levels of clinical expertise
Results
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Review readmission data submitted by providers
Generate a trending report and list of patients
Feedback to hospital
Random chart reviews with narrative
Issues
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15-20 charts reviewed per month, over 3 months
7-day readmission review
Cross-setting chart review (downstream providers)
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
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IHI STAAR: Worksheet A
Details and documentation
• Days between discharge and readmission
• Follow-up physician visit scheduled prior to discharge
– Patient attended office visit
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Urgent clinic/ED visit before readmission
Functional status on discharge
Clear discharge plan
Teach-back
Reasons for readmission
Social conditions contributing to readmission
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
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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
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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.
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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/Readmissio
nsDiagnosticWorksheet.aspx
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Thank you!
ICPCA National Coordinating Center
– www.cfmc.org/integratingcare
– Tom Ventura (tventura@cfmc.org)
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