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Using Root Cause Analysis to Reduce Hospital Readmissions

Jennifer Wieckowski, MSG

Health Services Advisory Group of California, Inc.

(HSAG-California)

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Purpose of the 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.

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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.

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National Coordinating Center http://www.cfmc.org/caretransitions/toolkit.htm

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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.

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Using RCA to Drive Intervention Selection—Good Example

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Using RCA to Drive Intervention Selection—Poor Example

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Using RCA to Drive Intervention Selection—Good Example

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Variety of RCA Tools

Patient/family interviews Care coordinator interviews Medical record reviews Process mapping Cause-and-effect diagrams “5 Whys”

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Patient/Family Interviews

Semi-structured telephone or face-to-face interviews with patients who were readmitted

Helps to identify opportunities for improvement from the patient’s perspective

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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.

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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.

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Process Mapping

Observe discharge and admission processes directly, interview process owners, and map the processes.

Elicit staff perceptions about where communication issues and gaps may occur.

Clarify specific roles and contributions of those involved in the process.

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Cause-and-Effect Diagram(Fishbone Diagram)

Visually illustrates potential causes of high readmissions

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“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.

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“5 Whys” Example

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“5 Whys” Example (cont’d)

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Results from Previous Care Transition RCAs

“Rocket science is helpful, but not required.”

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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.

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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

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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.

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For More Information

Mary Fermazin, MD, MPAChief Medical Officer, HSAG-California

Jennifer Wieckowski, MSGProgram Director, Care Transitions, HSAG-California

700 North Brand Blvd., Suite 370

Glendale, CA 91203

818-265-4650

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www.hsag.comThis material was prepared by Health Services Advisory Group of California, Inc., the Medicare Quality

Improvement Organization for California, 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. CA-10SOW-8.0-101311-01

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