ROOT CAUSE ANALYSIS

1. LORNA MARTIN CAH & SMALL RURAL LEARNING COMMUNITY APRIL 25, 2012 ROOT CAUSE ANALYSIS

2. What is a RCA?Using example of a Readmission • Process for identifying basic or causal factors in outcomes • A way of looking at unexpected events and outcomes to determine underlying causes • A way of making decisions and look for sustainable solutions based on data and facts • An RCA focuses primarily on systems and processes, not individual performance • An RCA is usually broken down into: • Collecting data, i.e. 30-day readmits • Hospital Consumer Assessment to identify data • Core Measure scores • Analyze data • Chart review of readmitted patients • Patient/Family interviews • Discharge process mapping

3. TOOLS • Medical Record Reviews • Patient/Family Interviews • Process Assessment • Process Mapping • Drill down to “WHY’s

4. Drill Down to 5 Whys • This technique can help to identify the root cause of a problem, determine the relationship between different root causes of a problem, and is simple and easy to complete without statistical analysis ? ? ?

5. Completing 5 Whys • Write down the specific problem • Ask why problem occurred and record answer • If answer provided does not identify problem, ask “Why” again and continue until root cause is identified • This process usually is complete within 5 tries, but can take more or less, based on the problem

6. FOCUS PDSAProcess Improvement Communication Tool Find a process to improve • Identify a service or care process to improve • Determine a best practice • Select an AIM for your improvement • Is there a Policy or Regulation? • If there is no standard, state your new practice in the next column

7. Organize a team: • You need a team – preferably stakeholders for success • Identify how process is done now • Do a Process Map to show order of each step • Gather baseline data about current process to represent order • Collect baseline data about process