Objectives for Root Cause Analysis Identify a problem in a structured way Eliminate root causes of waste / problems Prevent similar problems from reoccurring Make future reoccurrences visual
Problem Definition Tree/5 Whys Difficulty incorporating ESAS into everyday practice Too many other things to keep track of during visit Physician not discussing ESAS survey with Patient Don’t fully understand the assessment Not the largest contributor Not the largest contributor Problem Why? Why? Why? Forget to include as a part of visit Why? No standard created to prompt use of assessment Why? Identified root cause
Things to consider • Use a pencil with an eraser • At first it will be awkward and frustrating • Do not let it become the 5 who’s • Causes that one can act upon • Often comes down to: “No standard existing for a particular problem” or “an existing standard which is not being followed” • There is often more than one root cause, come up with several!
Difficulty incorporating ESAS into everyday practice Physician not discussing ESAS survey with Patient Therefore Test – Checking Chain Logic Therefore Therefore Forget to include as a part of visit Therefore No standard created to prompt use of assessment Start @ Root Cause & Work Up To The Problem
Address the root cause…. MOQC Change Packet • IHI model for improvement
Questions? Contact MOQC at CC-MOQC-TEAM@med.umich.edu
Resources • AHRQ Agency for Healthcare Research and Quality PSNet. Root Cause Analysis. Retrieved December 10,2013, from http://psnet.ahrq.gov/primer.aspx?primerID=10 • iSix Sigma. Determine Root Cause: 5 whys. Retrieved December, 10, 2013, from http://www.isixsigma.com/tools-templates/cause-effect/determine-root-cause-5-whys/ • The Joint Commission. Framework for Conducting a Root Cause Analysis and Action Plan. Retrieved December 10, 2013, from • http://www.jointcommission.org/Framework_for_Conducting_a_Root_Cause_Analysis_and_Action_Plan/ • DoHerty, Kevin. (2013). Foundations of Quality Improvement [Power Point slides]. Retrieved from MOQC.