A key step in building a high performing organization is to adopt the Toyota principle of “stopping to fix problems”. Leaders will often adopt this principle but fail to effectively execute on it because they pursue solutions without identifying the cause of the problem. This approach places the organization in a tampering mode where there is a limited probability of success. The root cause analysis was introduced in recognition of this problem-solving error, establishing cause identification as the first step in problem solving. The 5 Whys is typically the go to tool when initiating a root cause analysis (RCA). While this approach has utility, it tends to become less effective when addressing complex processes where there may be multiple opportunities for improvement.
In healthcare we encounter a higher level of complexity when evaluating patient outcomes as multiple factors come into play in driving the results. More specifically, a patient’s outcome may be determined by provider effectiveness, process integrity, process reliability, and patient behavior as well as a multitude of social determinant of health issues including finances, education, support structure and living environment. An RCA on patient outcomes must consider these multiple factors for service providers to learn and improve.
Another RCA tool, Failure Modes Analysis, is arguably a better initial approach to addressing the more complex healthcare processes. Adopting this tool will lead to effective learning from adverse patient outcomes, opening opportunities to improve your healthcare delivery systems.
A good example for utilizing this tool is in the prevention of 30-day all cause readmissions. This analysis begins by identifying the steps in the pre and post discharge process required to reduce the probability of a readmission. These steps include:
1. Visit the patient in the hospital to support the discharge planning process assuring the post-discharge services and actions needed for a successful outcome are identified. Key components of this plan include:
a. Establishing an appropriate plan for discharge disposition (ex. home, assisted living, rehab, SNF) as well as the timing of the discharge.
b. Assure patient has access to required resources to execute the discharge plan.
c. Assure patient understanding and acceptance of the discharge plan.
2. Outreach to patient post discharge to complete a transitions of care assessment and assure the discharge plan is initiated. Key actions and considerations are:
a. Complete a medication reconciliation
b. Assure the patient visit with the physician takes place within 7 days
c. Assure patient complies with medication plan
d. Check on patient lifestyle compliance
e. Assure patient has access to required resources
3. Complete recurring patient follow-ups over the next 30 days to make sure the care plan is being followed and to make additional interventions as needed.
Having identified the steps needed to reduce the probability of a readmission, the care team can adopt the failure mode analysis process to determine the causes for a readmission. Exhibit 1 provides a guide for conducting a failure mode analysis on 30-Day readmissions.
The findings from this analysis will typically fall into four categories
• A failure in system integrity. In this finding we identify areas where the system’s current processes do not include one or more of the steps required to reduce the probability of a readmission. For example, the system does not have a process in place to assure the patient has the transportation needed to comply with the discharge plan. System improvement will require efficiently adding these steps where a cost benefit analysis demonstrates a positive return on the investment.
• A failure in system reliability. This finding identifies established process steps that were missed in the case under analysis. Missed steps would include, not visiting the patient in the hospital, failure to connect with the patient post discharge, not completing the physician visit within 7 days, and not providing a required intervention. The 5 Whys may be utilized to determine the reason for the missed steps. Improvements will typically require additional system controls to assure these steps are not missed in the future.
• A failure in effectiveness. In this case all the necessary steps were taken but the patient was still readmitted. Linking the reason for the readmission to the step(s) intended to address this issue is a first step in addressing effectiveness failures. Next the care team should identify improvements they can make in each applicable step to prevent the recurrence of an effectiveness failure.
• Readmission was not preventable. A good deal of scrutiny must be applied before coming to this conclusion. Even in these situations the care team can learn and improve by evaluating the circumstance of the readmission and determining how the circumstances may have been addressed to prevent future readmissions. This level of evaluation typically requires a longer-term perspective with a population health focus.
As the above example demonstrates, the solutions to a problem will vary dependent on the cause. Accordingly, determining the cause is a vital first step in fixing a problem. The failure mode analysis is a process focused approach intended to lead care teams to the service gap that caused the problem. This approach will serve as a valuable tool for the organization to learn and improve from each undesired outcome.
Exhibit 1
Readmission Failure Mode Analysis & Improvement Planning
