LORNA MARTINCAH & SMALL RURALLEARNING COMMUNITYAPRIL 25, 2012

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

Medical Record Reviews

Patient/Family Interviews

Process Assessment

Process Mapping

Drill down to “WHY’s

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

? ? ?

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

Find a process to improveIdentify 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

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