Care Transformation

Mary Beth Mitchell

Root Cause Analysis (RCA) has been widely used only as an error analysis tool to understand serious adverse events, and is a methodical process utilized to get to the base understanding of the cause(s) of an event. It is often viewed by many as an exhaustive process and thereby only employed in specific serious event circumstances. The process’s strict discipline is often viewed as a hindrance and time consuming. However, the clear benefit when it is used, is not only to identify the mistake but also to get to the mechanisms that contributed to the mistake. The premise is to recognize that humans will make errors with the responsibility of the organization to identify both active and latent errors to reduce events from occurring.

Many organizations utilize this technique for serious events due to the perceived exhaustive process and limitations in staff knowledge. However, if staff are educated and the RCA process is utilized to understand clinical decision making, it can lead to improved understanding of the “why” in hard-to improve processes while yielding multiple actionable root causes. Sequential RCA’s may yield yet a higher return in understanding as they can demonstrate patterns in the decision-making process by a clinician. The following is an example of how sequential RCAs were performed to determine patterns that led to readmission for CHF patients in a Home Health Department.

This is an example of the methodology employed to understanding and reducing the likelihood of less than-serious events. Sequential RCAs were conducted on Congestive Heart Failure (CHF) readmissions from a Home Health Organization to examine the decision making that led to the re-hospitalization. The RCA process was deployed: a timeline was written, identification of the steps that were taken and what steps the organization would have wanted taken to identify the gaps that occurred. The key focus was ongoing interviews with the staff who made clinical decisions along the way. Each step in the timeline was a visit or phone call interaction with the patient/family/caregiver, and each staff member involved in the interaction was interviewed with the interviewer asking questions such as “Help me understand why that decision was made”.

"The premise is to recognize that humans will make errors with the responsibility of the organization to identify both active and latent errors to reduce events from occurring"

Once the events were reviewed and the interviews conducted, a multidisciplinary team analyzed the decision points which were then grouped into reasons. For example, in this agency, CHF patients were either on a Heart Failure Pathway (the clinician had to call for a medication adjustment) or a Heart Failure Diuretic Protocol (the clinician already had medication adjustments available in protocol). The pathway was being utilized both for patients who did not regularly need a medication adjustment, and for those who needed nonstandard adjustments. The latter left much interpretation and decision-making up to the clinician, resulting in inconsistency of timing of calls to the cardiologist for a medication adjustment based on changing symptoms. Once the recurrent themes came to light, the protocol could

be adjusted with specific decision-making points added to aid the clinician and reduce variability, such as individualized yet specific direction on when to call.

Identification of actionable items that go beyond education is key to improvement with hardwiring of the action items being essential. There were additional findings that assisted with improved specificity in the pathways and protocol and actions were then hardwired into the Electronic Medical Record (EMR).

The clinical and the informatics staff were both involved in how to redesign the pathway which is important to ensure that the electronic prompting of action resulted in the intended outcome. The result not only reduced the readmission rate for the CHF patients but also reduced the overall readmission rate for the agency by 6% in 5 months.

The findings demonstrate that RCA is a useful tool to gain insight into the why and has a broad case use. RCA has long been considered a time-consuming process and can be if the organization has not established a standard and consistent methodology. However, when the process to be used is clearly identified, the RCA tools to be used are specified and the leadership is educated on the process and purpose, it can be used very efficiently and in many circumstances beyond serious events.