Guide to Causal/Barrier Analysis

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					    Information for Health Care Improvement

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                                             Guide to Causal/Barrier Analysis

        Objectives
                   Learn about root cause analysis and why it is important.
                   Obtain tools to assist your organization in conducting root cause analysis.
                   Review PIP documentation requirements for Activity VII.


        What is a Root Cause?
                   A root cause is the main reason (or reasons) why something happened or did not happen.
                   Resolving a root cause should prevent a recurrence of the problem and improve
                    outcomes.

              Root cause analysis is a way of looking at unexpected events and undesirable outcomes to
              determine all of the underlying causes and recommend changes that are likely to improve
              them. It is a systematic approach to get to the true root causes of our process problems.

              For PIPs, root cause analysis is also known as causal/barrier analysis. The causes and
              barriers identified are reasons (root causes) why the study indicator results are not meeting
              performance standards.

              Examples of a symptoms-focused approach:

              1) “An error occurred. It was because workers are careless. We need to train them to be
                 more careful.”
              2) “We don’t have the time or resources to really get to the bottom of this problem.”
                 www.nasa.gov

              Focusing on the root cause:

              “There was a defect in the system. People are only part of the process. We need to find out
              why the error occurred and implement actions so it won’t happen again.” www.nasa.gov

              Root cause analysis should:

                   Primarily focus on systems and/or processes.
                   Identify changes that can be made in systems and/or processes.




      FTP Site Document                                                                                              Page 1
      Health Services Advisory Group, Inc.                                                 PIP-Val_Analysis Guide_V1.0_0411
    Information for Health Care Improvement

www.hsag.com




        Why Should You Do Root Cause Analysis?
                   The problem must be fully understood before taking action to fix it.
                   It will help the organization understand the barriers to achieving desired outcomes.
                   Interventions can be streamlined and focused to address the barriers.
                   It is a PIP documentation requirement (critical element).
                   The overall goal is to achieve improvement in the care and services provided to members.


        Methods


        Brainstorming

                   Everyone involved in the process can participate.
                   Team generates as many ideas as possible.
                   Can be done in a short period of time.
                   Promotes creativity and participation.
                   Focus on quantity of ideas.
                   Team members should not criticize ideas.

              “Brainstorming is a group creativity technique designed to generate a large number of ideas
              for the solution of a problem.” http://en.wikipedia.org


        Five Whys

                   Simple problem-solving technique.
                   Gets to the root of the problem quickly.

              Five whys example*:

              Problem Statement: You are on your way home from work and your car stops in the middle
              of the road.

              1) Why did your car stop?
                 Because it ran out of gas
              2) Why did it run out of gas?
                 Because I didn't buy any gas on my way to work.




      FTP Site Document                                                                                           Page 2
      Health Services Advisory Group, Inc.                                              PIP-Val_Analysis Guide_V1.0_0411
    Information for Health Care Improvement

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              3) Why didn't you buy any gas this morning?
                 Because I didn't have any money.
              4) Why didn't you have any money?
                 Because I lost it all last night in a poker game.
              5) Why did you lose your money in last night's poker game?
                 Because I'm not very good at "bluffing" when I don't have a good hand.
              * Source: http://www.isixsigma.com


        Ways to Incorporate Member or Provider Input


        Surveys

                   Good for assessing satisfaction.
                   Usually include high level questions.
                   Survey design should be considered.


        Focus Groups

                   Capture perceptions, opinions, and attitudes.
                   Involve direct dialog with participants.
                   Useful for identifying dissatisfaction and establishing potential solutions.


        Tools

                   Process map (flow chart)
                   Fishbone diagram
                   Scatter diagram
                   Pareto chart
                   Run chart




      FTP Site Document                                                                                                Page 3
      Health Services Advisory Group, Inc.                                                   PIP-Val_Analysis Guide_V1.0_0411
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               Process Map/Flow Chart: A process map/flow chart is a pictorial representation that
               outlines all of the steps in a process.




               What is the value of a process map?
                   Provides a picture of the process.
                   Allows teams to agree on the process steps.
                   Examines which steps may impact the process performance.
                   Serves as a training tool to understand the complete process.
                   Allows you to analyze order of the steps.

               Flow chart analysis
                   Analyze flow chart of actual process.
                   Analyze flow chart of best (ideal) process.
                   Take steps to eliminate the differences and close the gaps.




      FTP Site Document                                                                                        Page 4
      Health Services Advisory Group, Inc.                                           PIP-Val_Analysis Guide_V1.0_0411
    Information for Health Care Improvement

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               First things first
                   Before you can improve a process, you need to know how it works.
                   Listen to all the members of your team, especially those who are the closest to the
                    process.
                   Share improvement ideas, then try them.

               Keep at it
                   If at first you don’t succeed, try again.
                   Look at others who perform the process well.
                   Borrow ideas.
                   Try again.
                   Keep going.


               Fishbone Diagram




                   Also known as a cause and effect diagram.
                   Explores many possible causes of a specific problem.
                   May help establish a common understanding of the problem.




      FTP Site Document                                                                                              Page 5
      Health Services Advisory Group, Inc.                                                 PIP-Val_Analysis Guide_V1.0_0411
    Information for Health Care Improvement

www.hsag.com




               Scatter Diagram




                   A visual display of data.
                   Shows the association between two variables.
                   Illustrates the strength of the correlation between variables.
                   Does not prove a causal relationship.

               Pareto Chart




                   A bar chart.
                   Bars rank in descending frequency of occurrence.
                   Use when studying more than one variable.



      FTP Site Document                                                                                        Page 6
      Health Services Advisory Group, Inc.                                           PIP-Val_Analysis Guide_V1.0_0411
    Information for Health Care Improvement

www.hsag.com




                   Can show where improvement should be focused.
                   20 percent of bars should show 80 percent of problem (80/20 rule).
                   Separates the “vital few” from the “useful many.”

               Run Chart




                   Displays data over time.
                   Good way to observe patterns.
                   Depicts how well or poorly a process is performing.
                   Will show if a process is changing over time.
                   Can evaluate to identify meaningful trends or shifts.


        PIP Documentation Requirements for Activity VII: Assess
        Improvement Strategies


        Evaluation Element #1 (critical):

              Interventions should be related to causes/barriers identified through data analysis and quality
              improvement processes.

                   The quality improvement process used to identify causes/barriers must be documented in
                    the PIP submission.




      FTP Site Document                                                                                            Page 7
      Health Services Advisory Group, Inc.                                               PIP-Val_Analysis Guide_V1.0_0411
    Information for Health Care Improvement

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        Evaluation Element #2:

              System changes that are likely to induce permanent change.

                   The PIP should include changes that will affect the system/process.


        Evaluation Element #3:

              Revised if the original interventions are not successful.

                   If the PIP does not show improvement, interventions should be revised or new
                    interventions added.
                   Causal/barrier or root cause analysis should be completed regularly throughout the PIP
                    cycle.


        Evaluation Element #4:

              Standardized and monitored if interventions are successful.

                   When the PIP has demonstrated success, interventions should be standardized and
                    monitored.


        Tips:

                   Try easy changes first. For example, modify a current process before creating a new
                    process.
                   Reflect on the results. Ask, “What did we expect to happen?” and “What did happen?”
                   Don’t be afraid to ask for help! Send technical assistance requests to
                    ddriscoll@hsag.com.




      FTP Site Document                                                                                             Page 8
      Health Services Advisory Group, Inc.                                                PIP-Val_Analysis Guide_V1.0_0411

				
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