LORNA MARTIN CAH & SMALL RURAL LEARNING COMMUNITY APRIL 25, 2012.
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Transcript of LORNA MARTIN CAH & SMALL RURAL LEARNING COMMUNITY APRIL 25, 2012.
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