Root Cause Analysis (RCA) Getting to the Root of the Problem

Transcription

1 Root Cause Analysis (RCA) Getting to the Root of the Problem

2 DRIVING IMPROVEMENT The focus is on three critical aims to make care better for everyone: Better patient care Better population health Lower healthcare costs through improvement

3 THE PURPOSE OF ROOT CAUSE ANALYSIS (RCA) Identify the root cause of readmissions at your hospital Identify patterns of readmissions specific to your community and its providers Use RCA results to guide targeting criteria and intervention selection

4 OVERALL PROCESS Collect data Analyze data Develop and evaluate corrective actions using Plan, Do, Study, Act (PDSA) cycle Implement successful corrective actions

5 VARIETY OF RCA TOOLS Patient/family interviews Care coordinator interviews Medical record reviews Process mapping Cause-and-effect diagrams The 5 Whys Process 5

6 PATIENT/FAMILY INTERVIEWS Semi-structured telephone or face-toface interviews with patients who were readmitted Helps to identify opportunities for improvement from the patient s perspective

7 CARE COORDINATOR INTERVIEWS Conduct individual and/or group interviews with care coordinators Identify patterns, trends, and opportunities for improvement from the staff member s perspective Formulate groups across settings or within provider teams, organizations, or specialties 7

8 MEDICAL RECORD REVIEWS Review randomly sampled hospital discharges and 30-day readmissions Common finding: Patient education is completed and documented, but patients need more in-depth understanding to be compliant 8

9 PROCESS MAPPING Clarify specific roles and contributions of those involved in the process Observe discharge and admission processes directly Interview process owners Map the processes Obtain staff perceptions about where communication issues and gaps may occur 9

10 COMMON PROCESS MAPPING SYMBOLS/SHAPES

11 CAUSE-AND-EFFECT DIAGRAM (FISHBONE DIAGRAM) Visually illustrates potential causes of high readmissions

12 THE 5 WHYS PROCESS 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 readmission problem, ask why again and record the answer Continue this process until your team agrees the problem s root cause has been identifiedusually takes 3-5 cycles

13 THE 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

14 THE 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

15 Results from Previous Care Transition RCAs Rocket science is helpful, but not required.

16 RESULTS FROM PREVIOUS CARE TRANSITION RCAs (cont d) RCAs revealed remarkably consistent results Patients experienced readmissions because of: Unmanaged worsening of their conditions The use of suboptimal medication regimens Returning to emergency departments instead of accessing a different type of medical service

17 INTERVENTIONS TO IMPROVE CARE TRANSITIONS Care Transitions Intervention Transitional Care Model INTERACT II HHQI Best Practice Intervention Packages Project Boost Bridge model Project RED GRACE Model STAAR Initiative

18 SYSTEM-LEVEL DRIVERS OF READMISSION Poor provider-patient interface Medication 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

19 BUILDING A COMMUNITY-BASED PROGRAM Root Cause Analysis Did Intervention Address Driver ID Driver of Readmission Measure Intervention Select Intervention

20 INTERVENTIONS AND DRIVERS Intervention Patient Activation Standard Process Information Transfer Care Transitions Intervention Transitional Care Model INTERACT II HHQI Best Practices Project Boost Bridge Model Project RED GRACE Model STAAR Initiative

21 USING RCA TO DRIVE INTERVENTION SELECTION GOOD EXAMPLE RCA Technique: Process Mapping Hospital Discharge Intervention directly addresses root cause identified Key Findings: No standard process, discharge is chaotic, varies based on staff Intervention improves hospital discharge process Intervention Selection: Project RED 21

22 USING RCA TO DRIVE INTERVENTION SELECTION POOR EXAMPLE RCA Technique: Process Mapping Hospital Discharge Intervention does not address root cause identified Key Findings: No standard process, discharge is chaotic, varies based on staff Intervention improves patient activation and engagement Intervention Selection: Care Transitions Intervention 22

23 USING RCA TO DRIVE INTERVENTION SELECTION GOOD EXAMPLE RCA Technique: Interview all patients who are currently in the hospital for a 30-day readmission Intervention directly addresses root cause identified Key Findings: (1) Patients did not understand/did not correctly take medications, and (2) Patient condition worsened; unsure of what to do, so patients called 911 or came to ED Intervention improves patient activation and engagement addresses four pillars (PHR, red flags, medication management, and follow-up) Intervention Selection: Care Transitions Intervention 23

24 THREE BASIC SYSTEM GAPS Lack of engagement or activation of patients and families Lack of standard processes among providers for transferring patients No medical responsibility Ineffective or unreliable sharing of relevant clinical information

25 RCA CONCLUSION 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

26 COMMUNITY BASED CARE TRANSITIONS PROGRAM (CCTP) APPLICATION 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

27 COMMON APPLICATION ERRORS The community-specific RCA is missing The community-specific RCA is present but not explicitly tied to the methodology for targeting high-risk beneficiaries and the proposed interventions CCTP Application Link

28 NATIONAL COORDINATING CENTER

29 QUESTIONS/DISCUSSION Betty DeBlasio RN QI Specialist Qsource

30 Material prepared by Qsource, the Medicare Quality Improvement Organization (QIO) for Tennessee, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Contents presented do not necessarily reflect CMS policy. Publication No. 12.CPC