Florida Quarterly Meeting Root Cause Analysis
description
Transcript of Florida Quarterly Meeting Root Cause Analysis
![Page 1: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/1.jpg)
Florida Quarterly Meeting Florida Quarterly Meeting Root Cause Analysis Root Cause Analysis
January 12, 2011
Christy Hormann, MSW, CPHQProject Leader-PIPs
Don Grostic, MSAssociate Director Research & Analysis Team
![Page 2: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/2.jpg)
Objectives• Learn about root cause analysis and discuss why it
is important.
• Obtain tools to assist your organization in conducting root cause analysis.
• Review PIP documentation requirements for Activity VII.
2
![Page 3: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/3.jpg)
Root Cause Analysis
What is a root cause?
• A root cause is the main reason(s) why something happened or did not happen.
• When resolved, it should prevent a recurrence of the problem and improve outcomes.
3
![Page 4: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/4.jpg)
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.
4
![Page 5: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/5.jpg)
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.
5
![Page 6: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/6.jpg)
Root Cause Analysis
A symptoms-focused approach:
“An error occurred. It was because workers are careless. We need to train them to be more careful.”
www.nasa.gov
6
![Page 7: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/7.jpg)
Root Cause Analysis
Focusing on the root cause:
“There was a defect in the system. People are only part of the process. We need to find out why the error occurred and implement actions so it won’t happen again.”
www.nasa.gov
7
![Page 8: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/8.jpg)
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.
8
![Page 9: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/9.jpg)
Why should you do Root Cause Analysis?
9
![Page 10: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/10.jpg)
Root Cause Analysis
The problem must be fully understood before action is taken to fix it.
10
![Page 11: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/11.jpg)
Root Cause Analysis
Data analysis
Root cause analysis
Develop and implement solutions
11
![Page 12: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/12.jpg)
Root Cause Analysis
1. Will help the organization understand the barriers to achieving desired outcomes.
2. Interventions can be streamlined and focused to address the barriers.
3. PIP documentation requirement (critical element).
12
![Page 13: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/13.jpg)
The overall goal is to achieve improvement in the care and services provided to members.
13
![Page 14: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/14.jpg)
Root Cause Analysis Tools and Techniques
14
![Page 15: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/15.jpg)
Root Cause Analysis
Methods:
• Brainstorming• Five whys
15
![Page 16: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/16.jpg)
Brainstorming
“Brainstorming is a group creativity technique designed to generate a large number of ideas for the solution of a problem.”
http://en.wikipedia.org
16
![Page 17: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/17.jpg)
Brainstorming
• Everyone involved in the process can participate.
• Team generates as many ideas as possible. • Can be done in a short period of time.
17
![Page 18: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/18.jpg)
Brainstorming
• Promotes creativity and participation.
• Focus on quantity of ideas.
• Team members should not criticize ideas.
18
![Page 19: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/19.jpg)
Brainstorming
“We need good ideas and we need them nowSo put your heads together and we’ll write them down
There’s no bad ideas when you’re brainstorming.”
19
![Page 20: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/20.jpg)
Five whys
• Simple problem-solving technique.• Gets to the root of the problem quickly.
20
![Page 21: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/21.jpg)
Five whys Example
Problem Statement: You are on your way home from work and your car stops in the middle of the road.1. Why did your car stop? - Because it ran out of gas.2. Why did it run out of gas? - Because I didn't buy any gas on my way to work.3. Why didn't you buy any gas this morning? - Because I didn't have any money.4. Why didn't you have any money? - Because I lost it all last night in a poker game.5. Why did you lose your money in last night's poker game? - Because I'm not very good at "bluffing" when I don't have a good hand.http://www.isixsigma.com
21
![Page 22: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/22.jpg)
Root Cause Analysis
Ways to incorporate member or provider input:
• Surveys• Focus Groups
22
![Page 23: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/23.jpg)
Surveys
• Good for assessing satisfaction.• Usually high level.• Survey design should be considered.
23
![Page 24: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/24.jpg)
Focus Groups
• Obtain perceptions, opinions, and attitudes.• Direct dialog with participants.• Useful for dissatisfaction and establishing potential
solutions.
24
![Page 25: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/25.jpg)
Root Cause Analysis
Tools:
• Process Map/Flow Chart• Fishbone Diagram• Scatter Diagram• Pareto Chart• Run Chart
25
![Page 26: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/26.jpg)
Process Map / Flow Chart
A process map/flow chart is a pictorial representation that outlines all of the steps in a process.
26
![Page 27: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/27.jpg)
What is the Value of a Process Map?
• Provides a picture of the process. • Allows teams to agree on the process steps.• Examine which steps may impact the process
performance.• Serves as a training tool to understand the
complete process.• Allows you to analyze order of the steps.
27
![Page 28: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/28.jpg)
Basic Flow Chart Shapes
Start or end
Decision point
Process step
No
Yes
28
![Page 29: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/29.jpg)
Flow Chart Example
29
![Page 30: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/30.jpg)
Flow Chart Analysis
• Analyze flow chart of actual process.• Analyze flow chart of best (ideal) process.• Take steps to eliminate the differences and
close the gaps.
30
![Page 31: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/31.jpg)
First Things First• Before you can improve a process, you need to
know how it works.• Listen to all the members of your team,
especially those who are the closest to the process.
• Share improvement ideas.• Try them.
31
![Page 32: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/32.jpg)
Keep At It• If at first you don’t succeed, try again.• Look at others who perform the process
well.• Borrow ideas.• Try again.• Keep going.
32
![Page 33: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/33.jpg)
Fishbone Diagram
• Also known as a cause and effect diagram.
• Explore many possible causes of a specific problem.
• Can help establish a common understanding of the problem.
33
![Page 34: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/34.jpg)
Example
Fishbone Diagram
34
![Page 35: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/35.jpg)
Scatter Diagram
• A visual display of data.• Shows the association between two
variables.• Illustrates the strength of the correlation
between variables.• Does not prove a causal relationship.
35
![Page 36: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/36.jpg)
Scatter Diagram
36
Example
![Page 37: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/37.jpg)
Pareto Chart
• A bar chart.• Bars rank in descending frequency of
occurrence.• Use when you are studying more than one
variable.
37
![Page 38: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/38.jpg)
Pareto Chart
• Can show where improvement should be focused.
• 20 percent of bars should show 80 percent of problem. The 80/20 rule.
• Separates the “vital few” from the “useful many.”
38
![Page 39: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/39.jpg)
Pareto Chart
39
Example
![Page 40: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/40.jpg)
Run Chart
• Displays data over time.
• Way to observe patterns.
• Depicts how well or poorly a process is performing.
40
![Page 41: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/41.jpg)
Run Chart
• Will show if a process is changing over time.
• Can evaluate to identify meaningful trends or shifts.
41
![Page 42: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/42.jpg)
Run Chart
42
Example
![Page 43: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/43.jpg)
PIP Documentation Requirements
• Activity VII: Assess Improvement Strategies
• Four evaluation elements (1 critical)
43
![Page 44: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/44.jpg)
Activity VII
• Evaluation Element #1 (critical): Interventions should be related to causes/barriers identified through data analysis and quality improvement processes.
• The quality improvement process used to identify causes/barriers must be documented in the PIP submission.
44
![Page 45: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/45.jpg)
Activity VII
• Evaluation Element #2: System changes that are likely to induce permanent change.
• The PIP should include changes that will affect the system/process.
45
![Page 46: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/46.jpg)
Activity VII
• Evaluation Element #3: Revised if the original interventions are not successful.
• If the PIP does not show improvement, interventions should be revised or new interventions added.
• Causal/barrier or root cause analysis should be completed regularly throughout the PIP cycle.
46
![Page 47: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/47.jpg)
Activity VII
• Evaluation Element #4: Standardized and monitored if interventions are successful.
• When the PIP has demonstrated success, interventions should be standardized and monitored.
47
![Page 48: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/48.jpg)
Activity VII
48
Activity VIIa: Implement intervention and improvement strategies (interventions for improvement as a result of analysis). List chronologically the interventions that have had the most impact on improving the measure. Describe only the interventions and provide quantitative details whenever possible (e.g., “Hired four customer service representatives” as opposed to “Hired customer service representatives”). Do not include intervention planning activities.
Date Implemented (MMYY)
Check if
Ongoing
Interventions Barriers That Interventions Address
Describe the process used for the causal/barrier analyses that led to the development of the interventions.
![Page 49: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/49.jpg)
Activity VII Example
49
Activity VIIa: Implement intervention and improvement strategies (interventions for improvement as a result of analysis). List chronologically the interventions that have had the most impact on improving the measure. Describe only the interventions and provide quantitative details whenever possible (e.g., “Hired four customer service representatives” as opposed to “Hired customer service representatives”). Do not include intervention planning activities.
Date Implemented (MMYY)
Check if
Ongoing
Interventions Barriers That Interventions Address
2009 Site visits Lack of knowledgeTelephone calls This intervention was implemented to remind the member
of the required appointment.
Describe the process used for the causal/barrier analyses that led to the development of the interventions.
![Page 50: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/50.jpg)
Activity VII Example
50
Activity VIIa: Implement intervention and improvement strategies (interventions for improvement as a result of analysis). List chronologically the interventions that have had the most impact on improving the measure. Describe only the interventions and provide quantitative details whenever possible (e.g., “Hired four customer service representatives” as opposed to “Hired customer service representatives”). Do not include intervention planning activities.
Date Implemented (MMYY)
Check ifOngoing Interventions Barriers That Interventions
Address02/09 X Provider site visits to the top five high-volume
providers. During the visits, our plan representative reviewed with the provider the required appointment schedule. The providers were also given a list of members that had not yet received their annual visit. This intervention will be completed on a quarterly basis.
The providers were not aware of the schedule for the appointments and were not notified when members had not yet received their annual visit.
04/09 X Contacted members by telephone to notify them that it was time for their annual appointment. If the member was not reached by telephone, a follow-up letter was sent.
Members not aware of benefits for this service and also not aware of the need for the annual appointment.
06/09 Updated the website to allow providers to access whether members had received their annual appointment.
Providers did not have access to whether members received their annual appointment.
Describe the process used for the causal/barrier analyses that led to the development of the interventions. The Quality Improvement Committee meets on a quarterly basis and conducted a cause and effect diagram in January 2009 (see attached) to identify the causes/barriers for why members are not receiving their annual appointment. The committee revisits and reassesses the barriers semi-annually.
![Page 51: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/51.jpg)
Tips• Try easy changes first – for example, modify a
current process before creating a new process.
• Reflect on the results – Ask, “What did we expect to happen?” and “What did happen?”
• Don’t be afraid to ask for help! Send technical assistance requests to [email protected].
51
![Page 52: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/52.jpg)
Root Cause Analysis
52
![Page 53: Florida Quarterly Meeting Root Cause Analysis](https://reader035.fdocuments.in/reader035/viewer/2022070421/56816032550346895dcf5375/html5/thumbnails/53.jpg)
Questions
53