Root Cause Analysis in Aging Services

Root cause analysis (RCA) is a powerful systems analysis tool that informs performance improvement and drives purposeful change to prevent harm. With a focus on organization-wide system improvements, it also operationalizes stronger care and service delivery processes, which helps to ensure better financial sustainability.

Beyond offering a tool for mitigating harm, RCA helps fulfill federal quality assurance and performance improvement (QAPI) requirements for skilled nursing facilities and similar state requirements that are increasingly present for other settings on the aging services continuum including assisted living, and areas such as home health, hospice, and Programs of All-Inclusive Care for the Elderly.

Using a systems thinking approach to the RCA process acknowledges the importance of organizational culture as well as a culture of safety over individual blame, which enhances resiliency and the effectiveness in preventing adverse incidents from occurring.

However, those responsible for conducting RCAs should keep in mind that successful identification of root causes is not the ultimate outcome, but rather a means to a different end—creating sustainable performance improvement to address such root causes. Once identified, staff must address root causes through purposeful change and organizational development.

RCAs are not without challenges. They demand an investment in time and resources, and even when participants are committed to doing a fair and thorough investigation, they can be subject to the pitfalls discussed in this article.

The Root Cause Analysis and Action (referred to as "RCA squared" [RCA²]) model takes the RCA process one step further by emphasizing the identification and implementation of sustainable systems-based improvements without focusing on individual blame, staff performance, or punishment. Indeed, failure to make and implement sustainable, effective recommendations is one of the common pitfalls that ECRI has seen in its review of RCAs, and one that the RCA2 process is intended to mitigate.

The typical process for an RCA² investigation starts immediately after a hazardous event and follows these steps:

• Prioritizing the risks for investigation
• Analyzing the event
• Identifying the root cause(s)
• Developing solutions and corrective actions
• Implementing changes
• Tracking and measuring progress
• Soliciting feedback

Organizations should have a standardized process, within a clearly defined policy, that serves as a tool for navigating investigations, including how to choose which events to investigate, identifying the scope, and determining the focus. Team members can look to verified tools, such as the National Patient Safety Foundation (NPSF) RCA² guidelines that include a safety assessment code matrix—a severity and probability tool that can help RCA teams prioritize safety-related investigations and determine the appropriate level of investigation.

When building RCA² investigation policies NPSF recommends the following:

• Use a risk-based approach (rather than harm-based) to prioritize safety events, hazards, and vulnerabilities.
• Form RCA teams that include subject matter experts and novices.
• Enlist a leader with strong knowledge of safety science and the practice of RCAs, also enlist a patient representative.
• Use interviewing techniques, flow diagramming, action hierarchy, and other tools to facilitate the investigation and develop appropriate and robust actions.

Establishment of corrective actions is the ultimate goal and most important step in systems analysis. The Institute for Safe Medication Practices (ISMP) describes the effectiveness of risk-reduction strategies as the following hierarchy:

• High-leverage strategies are most effective because they can eliminate the risk of errors and associated harm by "designing out" hazards; however, they often require complex implementation plans.
• Medium-leverage strategies, which are easier to implement, reduce the likelihood of errors or minimize harm; however, they may need periodic updating and reinforcement.
• Low-leverage strategies, which aim to improve human performance, are easy and quick to implement; however, they are the least effective strategies for error prevention although frequently relied upon

See Figure 1 “ISMP’s Hierarchy of Effectiveness of Risk-Reduction Strategies."

Ideally, there should be a high or medium leverage action for each root cause. Lower leverage actions are often used as temporary measures or to support higher actions, given their level of effectiveness.

Despite having clearly identified investigation policies and procedures, many influences—both direct and indirect—can affect the overall quality and effectiveness an RCA. The following common pitfalls can contribute to problems in an organization's RCAs and their outcomes. They are drawn in part from ECRI's analysis of more than 750 RCAs from aging services organizations over the last decade that have ranged in focus from resident care issues and staffing issues to issues rooted in scope of service.

Stopping Short of Root Causes

RCA teams need to evaluate causal factors, contributing factors, and environmental conditions that enable performance gaps that lead to an incident. If these contributors are eliminated, events would be prevented, or severity would be reduced.

Root causes, however, differ from causal and contributing factors or conditions because they are part of larger organizational systems. Certain events or a trend of incidents may indicate there is more than one root cause, and therefore warrant additional investigation, resources, or corrective actions.

See Table for a comparison of these contributors in an example when a door alarm meant to alert staff to a resident's wandering and elopement did not function.

Some investigations may stop short of identifying as many root causes as possible, with a potential risk that problem-solving and improvement initiatives only address causal factors, contributing factors, and conditions, without correcting the deeper root causes. This allows the potential for harm through the repeated occurrence of similar incidents.

Lacking a Comprehensive RCA Team

Selecting the right team for conducting an RCA is critical. Team members should include the following:

• Team leader with an overall knowledge of the performance gap issue or process
• Mix of interdisciplinary management and frontline staff (clinical and nonclinical), representing varying professional backgrounds and levels of knowledge regarding best practices and current literature to support creative thinking and problem solving
• Administrative personnel to facilitate meetings, take notes, ensure adherence to the timeline, and review relevant literature, if appropriate
• Senior leader to champion the RCA; may not attend every meeting but will receive the RCA report and be accountable for action items and providing the team with resources

Staff who know the relevant circumstances of the event—but were not directly involved—should be chosen. Including subject matter experts from outside the organization may offer fresh perspectives.

Teams should consist of six to eight members depending upon the nature, complexity, and severity of the incident under investigation. Too many team members may hinder meeting facilitation and may reduce active participation, while too few may place extra burden on members and may risk extending the timeline of the RCA.

Lacking a Timeline and Sequence of Events

Because incidents can be more complex than they first appear, mapping out the sequence of events prior to and after an event can help uncover root causes and associated performance gaps. Treating the incident as a singular occurrence rather than a series of actions runs a greater chance of falling short of identifying root causes.

Take, for example, resident elopement or hazardous wandering incidents. If the RCA team only looks at a single elopement incident, the organization might implement measures to help mitigate the risks for one resident. However, if the RCA includes a timeline and sequence of events, team members may discover that this resident was newly admitted in the past week and has an underlying dementia that was not identified, which led to a misalignment of the resident's needs and the capabilities of the service line. In this instance, there are several organizational processes worth investigating for possible performance gaps which include:

• Faulty resident preadmission process
  • The resident's medical record was not successfully obtained prior to transfer or admission.
  • The resident was therefore erroneously admitted to a standard skilled-nursing unit rather than the dementia unit.
• Faulty resident admission clinical assessment process
  • The admission process did not include a new clinical assessment.
  • The clinical assessment did not accurately identify the cognitive impairment.

Avoiding Bias

Bias can negatively impact the analysis, interpretation, and identification of root causes, as well as the creation of performance improvement recommendations. Hindsight bias, in particular, is difficult to overcome in RCA investigations because the outcome of the event is known, and investigators are retracing the steps of those involved in the event.

This means investigators may have difficulty overcoming the impulse to judge or blame event participants for not following certain procedures or missing key circumstances. Working to understand the precise perspectives of those involved in the incident is key to avoiding hindsight bias and focusing on systems issues. Although it may be difficult to ensure a completely unbiased investigation, being critically aware of biases and remaining objective can protect against their influence.

Lack of a Clearly Defined Problem

Poorly defined problem statements can lead to scope creep—a situation where the analysis changes direction by focusing on performance improvement opportunities not directly related to the focus of the analysis. A scope that is too broad may also confuse the overall goal of the RCA, creating a risk that performance improvement projects will focus on issues that leave the root causes of the original problem unaddressed.

It may prove beneficial for organizations to approach the problem statement as a template with which the RCA team can check itself to make sure it stays on task and keeps the focus of the RCA within the area originally intended to identify and address the specific event performance gaps. The problem statement may also contribute to selecting the best process and outcome measures to assess whether performance improvement efforts are achieving the desired effect, especially when the problem statement identifies the types of incidents and any patterns or trends in those types of incidents.

Blaming Actors Instead of the System

The purpose of the RCA process is to focus on environmental circumstances of the error and the systems involved—not to assign blame. RCA investigations may be weakened by unjust punitive actions against event participants. It is important to remember that human error is often a sign of trouble deeper within the system.

Even if human error is identified as a root cause or contributing factor of an event, it does not signify the end of the investigation; it means that investigators need to delve deeper to understand the behavior of the people involved and the management issues that influenced their actions.

Incorporating this mindset into the organization's just culture and leadership approach, the RCA team may feel more empowered to challenge preconceived notions of "the way things are done" or "should happen" and optimize the RCA process that results in care-critical improvements.

Attempting to Conduct an RCA for Every Incident

Trying to conduct an RCA for every event and near miss quickly creates a sense of overwhelming burden and often leads to hesitation regarding undertaking RCA efforts. Therefore, organizations must take the time to develop and implement a decision-making paradigm that helps to guide decisions regarding when to conduct RCAs, including the following:

• Incidents, near misses, and unsafe conditions that have a potential for educating staff
• The frequency of an incident type or identifying the same root cause during several RCAs, known as common cause analysis
• Severity of an incident that considers actual or potential for serious harm to resident, staff, organization (eg, physical, financial, or reputational). Guidelines may include:
  • Injury or death
  • Number of persons adversely affected by the incident
  • Need for transfer to another provider for further assessment or treatment
  • Reporting requirements
  • The presence of nonroutine factors related to the incident (eg, involvement of media)

Adding a simple severity scale that includes a harm score to an organization's processes may also improve an organization's decision-making by narrowing the field of potential incidents.

A severity scale could be structured as follows:

• 0 – No injury or harm
• 1 – Minor injury or harm (abrasion, bruise, minor laceration): injuries that do not require substantial medical intervention
• 2 – Major injury or harm (fracture, head trauma): injuries that require substantial medical intervention or result in disfigurement or permanent loss of function without surgical repair
• 3 – Death

The initial severity of the event or near miss must be determined carefully. Under- or overestimating severity may adversely affect all subsequent postincident response and QAPI steps and may also undermine trust with residents, families, staff, authorities, the public, and other stakeholders.

As QAPI activities are conducted in good faith, participants may be concerned that information uncovered during the analysis could be used against an organization in litigation. These fears can inhibit a participant's desire to conduct or participate in performance improvement activities, including RCAs. However, when conducting an RCA, any avoidance of such issues may in itself contribute to an adverse event or a trend of events.

These concerns can be addressed in part through participation in a Patient Safety Organization (PSO). QAPI activities such as RCAs are encompassed in the definition of "patient safety work product" that can enjoy federal legal protections under the Patient Safety and Quality Improvement Act of 2005 (PSQIA).

PSQIA provides a protected legal environment in which providers may share information about patient safety events and QAPI work without the threat of information being used in litigation. By participating in a PSO, providers may voluntarily and confidentially report their patient safety and quality information to a PSO for aggregation and analysis and in return receive recommendations, protocols, best practices, expert assistance, and feedback from the PSO to improve the provider's patient safety activities.

This article is excerpted from "Root Cause Analysis in Aging Services: Considerations for Success." Download the complete white paper at https://www.ecri.org/white-paper-root-cause-analysis-in-aging-services/.