Root Cause

Deepest underlying cause(s) of positive or

negative symptoms within any process that,

if resolved, would eliminate or substantially

reduce the symptom.

RCA is just a tool

A tool used both reactively, to investigate

an adverse event that already has occurred,

and proactively, to analyze and improve

processes and systems before they break

down (Preuss, 2003).

RCA is…

0A system of problem solving methods aimed at identifying the root causes of problems or incidents.

0Predicated on the belief that problems are best solved by attempting to correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms.

0By directing corrective measures at root causes, it is hoped that the likelihood of problem recurrence will be

minimized.

Why Use RCA?

0 Helps identify the problem or challenge

0 Facilitates discussions

0 Eliminates Band-Aid approach

0 Helps resolve the problem

0 Provides rationale for strategy selection

Where Do I Start?

Principles of RCA

0 Consider RCA as a systematic investigation

0 A fresh perspective

0 Not a blame game

0 Not an IMMEADIATE fix

0 Digging deeper

0 Consider a sequence of events or timeline

0 Understand the relationship between cause and effect factors involved

General Process of RCA

0 Define the problem

0 Gather data/evidence

0 Ask WHY and identify the ROOT CAUSE linked to the identified problem

0 Identify solutions that will prevent a reoccurrence of the identified problem

0 Implement solutions

0 Observe solutions to ensure effectiveness

0 Be willing to reexamine the RCA if necessary

Steps to RCA Success

Step 1 ORGANIZE TEAM

Step 2 DEFINE PROBLEM

Step 3 CONDUCT DATA ANALYSIS

Step 4 DETERMINE ROOT CAUSES

Step 5 IMPROVEMENT PLANNING

Step 6 EVALUATE PROGRESS

Organize Team

0 Identify Members

0 Experience

0 Key Player

0 Process Orientated

0 Creative Thinker

0 Assign Duties

0 Consider Strengths

0 Create Accountability

0 Shared Responsibility

Define the Problem

0 What is the problem? 0 Is it my problem? 0 Can I solve it? Is it worth solving? 0 Is this the real problem, or merely a symptom of a larger one? 0 If this is an old problem, what's wrong with the previous solution?

0 Does it need an immediate solution, or can it wait? 0 Is it likely to go away by itself? 0 Can I risk ignoring it?

0 Does the problem have ethical dimensions? 0 What conditions must the solution satisfy? 0 Will the solution affect something that must remain unchanged?

Conduct Data Analysis

0 Examine & Discuss Data

0 Labs & Documentation

0 Logs & Reports

0 Medical Records

0 Conduct Data Analysis (View Objectively)

0 Patterns

0 Trends

0 Variability

Determine Root Cause

The Five Whys System Planning

Process

0 A process to seek root cause by asking “why?” five times in succession

0 Problem solving approach asks four questions: 0 “Where are we

now?’ 0 “Where are we

going?” 0 “How will we get

there?” 0 “What is holding us

back?”

Strategies for Determining Root Cause

The Five Whys

0 Team Exercise

0 Write down the identified problem

0 Ask WHY the problem happens and write down the answer

0 Repeat until the question is answered 5 times

0 The team should agree that the 5th answer IS the Root Cause of the problem – if not, repeat the exercise

0 If the Identified Root Cause is not within the control or influence of the team repeat the exercise

Problem • Car stopped on the way to work

Why?

• Why did the car stop? • Because it ran out of gas

Why?

• Why did the care run out of gas? • Because I didn’t buy gas on the way to work

Why?

• Why didn’t you buy gas on the way to work? • Because I didn’t have any money

Why?

• Why didn’t you have any money? • Because I lost it all last night in a poker game.

Why?

• 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.

Root Cause

Problem Solving Approach Where are we now?

What are the facts?

What worked? What can be improved?

Where are we going?

What do we want to achieve?

What is the expected outcome?

How will we get there?

What steps must we take to reach

the outcome?

Who are the key members of the

team?

What is holding us

back?

Is there support for improvement

planning implementation?

What roadblocks are before us?

Determining Root Cause

You know you found the Root Cause when:

0 Team Agrees on the root cause

0 Cause is logical, makes sense, and provides clarity to the problem

0 Cause is something you can influence and control

0 If the cause is solved, there is a realistic hope that the problem can be reduced or prevented in the future

Improvement Planning

The Improvement Plan should include:

0 Logical link between root cause and improvement activities;

0 Evidence-based practices;

0 Short- and long-term outcomes, timelines and action steps for improvement activities

0 Personnel (and partners) identified to develop, implement, monitor, and evaluate the improvement activity.

0 Collect Data to evaluate outcomes of improvement activities.

Evaluate Progress

0 Creates a process and habit for gathering, analyzing and using data.

0 Allows the team to determine whether it is effectively carrying out planned activities and the extent to which it is achieving its short-term and long-term outcomes.

QIP QIA Exercise

0 NW 16 & 18 ESRD QIP/QIA facilities only

0 Conduct a new RCA for Hyper-calcemia project

0 Email the new RCA back to Barb Dommert-Breckler by

Monday, May 9, 2016

QIP QIA 2016 Hypercalcemia

Network 18

0 552590 - Quotidian Dialysis 0 052846 - FMC-Inglewood 0 052699 - High Desert Hemodialysis 0 552543 - Home Dialysis Therapies of

San Diego-North 0 052556 - U.S. Renal Care Skypark

Dialysis 0 052867 - East Palmdale Dialysis

Center 0 052899 - U.S. Renal Care Los Angeles

Dialysis 0 052840 - U.S. Renal Care Long Beach

Dialysis 0 552636 - RAI-East Sixth Street-

Beaumont 0 552553 - Magnolia West Dialysis

Network 16

0 382563 - FMC FLORENCE OREGON

0 382551 - FMC REDMOND 0 502535 - FMC VALLEY

DIALYSIS UNIT 0 272503 - FMC BOZEMAN 0 502529 - FMC MOSES LAKE

DIALYSIS UNIT 0 272508 - FMC BUTTE 0 382500 - OREGON KIDNEY

CENTER 0 382512 - FMC EUGENE 0 502541 - YAKIMA DIALYSIS

CENTER 0 502544 - WESTWOOD

DIALYSIS CENTER

“If you don’t ask the right questions, you don’t get the right answers. A question asked in the right way often points to its own answer. Asking questions is the ABC of diagnosis. Only the inquiring mind solves problems.” – Edward Hodnett

Resources

Determine the Root Cause: 5 Whys. Retrieved on 4/22/16 from

http://www.isixsigma.com/index.php?option=com_k2&view=item&id=1308:&Itemid=49

OSEP 09-02 Timely Correction Memorandum. http://spp-apr-calendar.rrfcnetwork.org/explorer/view/id/446/?4

Preuss, P. G. (2003). Root Cause Analysis: School Leader’s Guide to

Using Data to Dissolve Problems. Larchmont, NY: Eye on

Education.