Risk Mitigation/Root Cause Analysis

Root Cause Analysis/ Risk Mitigation

1. Root cause analysis (RCA): is a systematic process for identifying the “root causes” of problems or events and an approach for responding to them. RCA is based on the basic idea that effective problem solving requires more than merely “putting out fires” for problems that develop but finding a way to prevent them.
2. Purpose: The purpose of the root cause analysis is to do an in-depth review and assessment into the reason for recurrence of critical events and identify areas of improvement opportunity in the Care Plan, thus ultimately reducing event recurrence and bettering outcomes for our participants. An RCA is required if the participant has experienced 4 or more critical events within 12 months. 
3. Goal: The goal of the RCA is to collect data, review each critical incident event and evaluate the information to find a common denominator or cause for the event. Evaluate the causes and see if there are corrective actions to mitigate re-occurrence. Such as:
   1. Reviewing with the MD for changes in plan of care
   2. Added services (not always PAS hours) that would benefit the participant
   3. Medication management
   4. Behavioral health
   5. Change to PAS agency (regarding service interruptions). 
4. Plan: This plan should be developed, implemented, and monitored. Please keep in mind that when you are required to complete an RCA, you are not calling the participant and asking them what their barriers are. This is an investigative process that requires a review by the Service Coordinator who will determine the reasonings and barriers by collaborating with the participant, PCP, and Nurse. 
5. Internal RCA Process:
   1. The Critical Incident Supervisor will receive an email from a representative of the Critical Incident Team at PHW with the RCA request. The CIS will open a task in Function Portal which will be assigned to the SC and SCS with a due date of two weeks.
   2. The SC is responsible for reviewing the incidents associated with the RCA and implementing the preventative plan. This is to be documented within Function Portal under “Root Cause Analysis” Session
   3. Once the RCA has been completed by the SC, it is the responsibility of the Supervisor to review and ensure that the RCA has been completed properly.
   4. The CIS will do a final review of the RCA and mitigation efforts to ensure quality prior to sending it to the Critical Incident Reviewer at PHW in order to close the case. 
   5. Please note that if at any time during the review from the CIS, if they find mistakes or little to no mitigation efforts documented, the CIS may reopen the task for the RCA to be revised by the SC.
6. RCA Revision:
   1. An RCA Revision will be requested if the participant recently had an RCA completed but then experienced a repeat transition. 
   2. The goal of this RCA is not to start over but to take the previously completed RCA, add the new critical incident event, and investigate further. New mitigation efforts may be required. 
   3. The SC must document in Function Portal under the “Root Cause Analysis Revision” Session