Quality Improvement Strategies

Root Cause and Subgroup Analyses

Root Cause Analysis

A way of looking at unexpected events and undesirable outcomes to determine all of the underlying causes and recommend changes that are likely to improve them.

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Root Cause Analysis

Also known as causal/barrier analysis. The causes/barriers identified are the

reasons (root causes) why the study indicator results are not meeting performance standards.

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Root Cause Analysis

Root cause analysis should:

Primarily focus on systems and/or processes. Identify changes that can be made in systems and/or

processes.

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Root Cause Analysis

Data analysis

Root cause analysisSubgroup analysis

Develop and implement solutions

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Root Cause Analysis

1.Will help the organization understand the barriers to achieving desired outcomes.

2.Allows interventions to be streamlined and focused to address the barriers.

3.Required for PIP documentation (critical element).

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Root Cause Analysis Tools

Brainstorming Survey Focus Group Process Map/Flow Chart Fishbone Diagram Scatter Diagram Pareto Chart Run Chart

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Subgroup Analysis

Why perform a subgroup analysis?

1.Determine if any subgroup within the population has a disproportionately lower rate that negatively affects the overall rate.

2.Develop targeted interventions to the identified subgroups, allowing the implementation of more precise, concentrated interventions.

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Population Subgroups

Race/Ethnicity

Age

Gender

Geographic Location

Provider

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Factors to Consider

Are the data elements for the subgroups – Available?– Accurate?– Complete?

Is the size of the subgroup– Adequate for analysis?– Require grouping?– Require additional subgroup analysis?

Are the subgroups reasonable, i.e., do they make sense? 10

Measure-Specific Examples

Follow-up after discharge for a mental illness

o Age

o Race and ethnicity

o Geographic location

– Zip codes

• Can be used as a proxy for race/ethnicity

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Measure-Specific Examples

Coordination of Care

o Geographic location

o Provider

– High volume

– Specific provider practice

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Initial Subgroup Analysis

Before implementing improvement strategies:

1)Identify disparities, i.e., do performance rates vary by subgroup?

2)Determine the impact of the disparity on the overall rate.

3)Identify subgroup-specific barriers, if applicable.– Root cause analysis– How can systems or processes be changed to

improve performance? 14

Ongoing Subgroup Analysis

After implementing improvement strategies:1)Evaluate the effectiveness of the

performance improvement strategy for all subgroups. – Monitor using interim measurements.– Consider rapid cycle improvement to test for

changes in rates and make “real-time” refinements.

2)Reevaluate barriers. – Root cause analysis.

3)Revise or standardize interventions.15

Activity VII-Implement Interventions and Improvement Strategies

Ensure that the root cause analysis process is completely documented in Activity VII.

Document when it was completed. Include who was involved (e.g., quality

improvement committee, work group, etc.). Provide the tools that were used (e.g.,

fishbone diagram, brainstorming, etc.).

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Activity VIII-Analyze Data and Interpret Study Results

If subgroup analysis is completed, document this in Activity VIII.

Include the outcome of the analysis as well as the follow-up activities planned as a result.

Subgroup analysis is not required; however, it is recommended as a way to target interventions.

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PIP due dates

PIPs due to HSAG on 12/14/11. Address all Partially Met and Not Met

scores from last year, as well as all Points of Clarification.

Reference the PIP Summary Form Completion Instructions for guidance.

HSAG is available to provide technical assistance. Contact ddriscoll@hsag.com to request.

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Questions/Comments

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