Resource of the Month -- Getting to the bottom of it: Root Cause Analysis

This post was written by Kristen Willard, M.S.

Root cause analysis (RCA) is another helpful skill you can add to your growing readmissions reduction toolbox. RCA is a systematic process in which you consider the causes for factors thought to contribute to specific– and usually undesirable – outcomes. In healthcare systems, these outcomes could be many: a patient fall, an increase in hospital-acquired infections, or in this case, the rehospitalization of a patient or patients with COPD.

While a discrete approach, root cause analysis is most useful as part of a larger quality improvement effort that aims to prevent undesired outcomes from re-occurring. As you can see from the three examples above, these outcomes can occur at either an organizational/system or individual level. No matter the outcome to be changed, RCA is a team-based effort and requires not only the involvement and investment of the organization’s staff, but the patient, as well; for the process to work well, the entire team must be on board.

The Centers for Medicare & Medicaid Services have published one helpful guide to process improvement involving root cause analysis. Let’s examine these quality improvement steps in the context of a COPD patient readmission:

Quality Improvement (QI) Steps: An Example

Step 1. Identify the event to be investigated. In this case, your event is the readmission of a patient to your facility due to COPD exacerbation.

Step 2. Select team members to be involved in the effort. In this particular situation, we would be interested in speaking with hospital staff who interacted most with the patient and who were aware of his treatment history as well as hospital policy and procedures.

Step 3. Describe what happened. Here, we would simply outline the objective details of what actually occurred. Informing this process would be information in the patient’s medical record, staff report, and the account of the patient himself. In our example: your 73-year-old patient was readmitted to your hospital with a COPD exacerbation following discharge to home from your facility 70 days prior.

Step 4. Identify factors that contributed to the event. In the case of a rehospitalization, there could be several patient-related variables that contributed to the admission, such as not seeking out a healthcare provider when symptoms worsened or not using medications as prescribed. It is equally important to consider factors external to the patient, as well; that is, facility and staff variables such as internal processes and staffing should be considered as influential when examining any events to include patient outcomes.

At this stage, you might collect information through the patient’s medical record, healthcare team interaction, review of facility processes as well as interviews with the patient and/or her family members. The Foundation has compiled a list of interview questions that prompts patients to discuss variables known to be related to poorer health outcomes and hospitalizations. This list can be modified to address other factors your COPD care team deem relevant to your patient population.

Patient Interview Questions

1. What do you think caused you to come back to the hospital?
2. Tell me what has happened since you were last here?
3. When did you start feeling worse?
4. What symptoms did you have – shortness of breath, increased sputum, cough, fever?
5. What did your doctor say at your office/medical home visit?
6. How did you get to your doctor’s office/medical home visit? Transportation?
7. If you have home health care, when did the nurse come to your home?
8. What medications did you get at the pharmacy since you went home? How did they make you feel?
9. Were you able to pay for your medications?
10. Were there instructions for your medications that you did not understand?
11. Show me how you use your inhaler.
12. What inhalers did you use? How many times in one day?
13. Did you use the nebulizer to lessen your symptoms? What happened?
14. How often do you use your nebulizer?
15. How much exercise or walking have you done each day?
16. Was your sputum thicker than normal? What color was it?
17. If you called your physician, what did he or she tell you do to?
18. Are you still smoking? If you are, when did you are start after you left the hospital?
19. How many pillows do you use at night? Do you sleep in a chair or a recliner?
20. How far can you walk without feeling short of breath?
21. Who is your main support person?
22. Do you have any pets? Where do they sleep?

Step 5. Determine root causes. Next, isolate the root causes of the event you identified in Step 1 and detailed in Step 3. A root cause is a factor in the historical timeline of an event that, if eliminated, would prevent the problematic event from taking place again. One common approach at this stage of your QI process is to use the “Five Whys” to drill down to the root cause of the issue.

In the Five Whys approach, you start with a contributing factor from Step 4 above – one that from your assessment seems like it could be related to your undesired outcome – and work sequentially to reach causes directly related to the event in question. To illustrate an example, let’s begin by using number 1 of the patient interview questions above. A case manager asks the following questions of a COPD patient:

1) What does the patient think caused him to come back to the hospital?

Patient communicated he got a bad chest infection.

2) Why does he think he got a bad chest infection?

He did not use his inhalers.

3) Why does he think he didn’t use his inhalers?

He didn’t fully understand the purpose of inhalers. He had more than two and couldn’t demonstrate how to administer them properly.

4) Why didn’t he understand the purpose and how to use them?

He didn’t receive a clear explanation of the benefits of different inhalers or training on how to use them when he received them.

5) Why didn’t he receive training?

There were not standardized systems in place to ensure that all patients prescribed inhalers received appropriate training before they were discharged.

You may not find the root cause of a particular issue in just five whys and may have to continue this process. At its conclusion, you will have a better grasp of one of the contributing factors and can then brainstorm ways to address it in the next step. You will repeat this process for major contributing factors until you have identified all root causes for an event.

Step 6. Determine appropriate interventions to address these root causes. In this case you must address both short- and long-term issues, this patient’s understanding of his inhaler regimen and the lack of standardized inhaler education at your facility. How do you best ensure this patient and others understand their medications? Consult our Resource Repository to learn more about patient education and empowerment approaches, including the evidence-based Teach-Back Technique. 

Step 7. Measure the success of your actions. Follow up is the key to gauging a successful QI effort. Be sure to specify the time frames and discrete variables that will represent success in your particular situation. In this example, you may consider outcomes such as 1) your patient demonstrating understanding of his inhaler regimen prior to discharge, 2) case manager follow-up outreach done at 7- day, 14-day, and then monthly intervals; and 3) the absence of a readmission through six months post-discharge. You would also develop metrics to gauge the success of your new global inhaler education approach once implemented. Note that the mindset now flips; while before we focused on the undesirable, how you measure your QI efforts at this stage will depend largely on your desired outcomes of interest.

Have you used Root Cause Analysis as part of your quality improvement efforts? Think this is something you might employ to improve your patient outcomes? Let us know!

Additional information on Root Cause Analysis and the Five Whys can be found here:

Root Cause Analysis Definitions and Resources 

CMS Five Whys Tool

This page was reviewed on March 5, 2020 by the COPD Foundation Content Review and Evaluation Committee