In my last blog, I talked about how PSDA can help QAPI. Another key piece to help QAPI is Root cause analysis — what happened? And why? How to prevent it?

Below are my top tips to help with root cause analysis. While I recommend seven steps, you can use more or less. The important thing is to have an organized process that everyone follows.

Step 1: Identify the problem/event

Start with the problem or event to be investigated. Collect and analyze various data from good sources. For example, data from incident reports, health department citations, family, resident, staff feedback.

Step 2: Organize the team

The team members will depend on the problem/event. The team members need to be familiar with the processes and systems associated with the problem.

People who have personal knowledge of what happened should also be included or interviewed.

Step 3: Describe what happened

Using the information gathered in step 1, create a timeline for the problem/event.  The timeline illustrates the sequence of steps that lead to the problem/event.  The resulting timeline should tell the “story” of what happened.

For this step, only describe the facts – root cause will be discussed in step 4.

Step 4: Conduct data analysis

Dig deeper into WHAT happened to understand WHY it happened. What was occurring during the timeline that escalated the possibility that some adverse event would occur?

Look at the contributing factors: situations, circumstances, or conditions. While one may not have caused the problem, all at the same time increased the chances.

Step 5: Identify root cause

Start to identify the source of the problem. Two of the most common tools are “the 5 whys” and “fishbone diagrams.”

A well-known example of “the 5 whys” involves the Lincoln Memorial in Washington D.C., which was deteriorating:

1. Why is the stone deteriorating? Because of the harsh chemicals used to clean it frequently.
2. Why are harsh chemicals used so often? Because of the large number of bird droppings.
3. Why are there so many bird droppings? Because the birds like to eat the spiders.
4. Why are there so many spiders? Because they like the spotlights on the monument.
5. Why are the spotlights needed? For people to see the monument when visiting.

Changing the time when the monument was lit resulted in a decrease of bird droppings, thereby decreasing the frequency of using the harsh chemicals.

Step 6: Create improvement plan

Now you can work on what is to be done, by whom, and when. These actions may need a new process or a change to a current process.

Consider the following:

• What can be done to prevent this from happening again?
• How could we change the way we do things?
• If this happened again, how could we quickly catch and correct it?
• How could we minimize any effect of the failure on the resident?

Step 7: Measure the success of changes

Make sure to monitor the implementation of these actions. This is usually the responsibility of the staff responsible for oversight of the QAPI program. Also, don’t forget to check progress and modify the plan as needed.

For more on root cause analysis, click here to download my white paper, “Managing Outcomes Using Root Cause Analysis.”

For additional QAPI resources, visit the CMS website. 

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