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

2.  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

3.  Medical Record Reviews  Patient/Family Interviews  Process Assessment  Process Mapping  Drill down to “WHY’s

4.  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 ? ? ?

5.  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

6. Find a process to improve  Identify 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

7.  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