Any adverse event that obstructs the development and success of an organization should be investigated to discover and understand the initiating cause of such event and to consequently establish corrective actions to prevent its recurrence in the future. This paper intends to:
- Identify the approach to be taken to address the reporting problem at Western Heights Hospital (WHH).
- To create a flowchart outlining the process to be taken in finding a solution to the organization’s reporting problem.
Approach to Address the Reporting Problem at Western Heights Hospital
As stated in the given scenario, the WHH is unable to report on various state and federally mandated quality measures. Definitely, this problem needs immediate attention as this process is essential to the organization to improve and maintain quality. As the clinical content manager and leader of all reporting efforts in the organization, it is my primary concern to address and find solution to the problem. My approach would be to perform a Root Cause Analysis (RCA). Conducting an RCA would help me discover and understand the initiating cause or causes of the problem and to develop corrective actions to prevent its recurrence in the future.
Root Cause Analysis
Below is a flowchart showing my steps to performing an RCA for the problem.
Identify the problem
Charter and appoint team facilitator and members
Describe the incident
Identify the contributing factors
Identify the root cause or causes
Eliminate the root cause or causes
Evaluate and measure
- Identify the problem. This step will include determining the problem to be investigated. The problem statement from the scenario would be, “The organization is unable to report on various state and federally mandated quality measures”. Also, included in this step is to gather preliminary information about the problem which can be discussed later by my team.
- Charter and appoint a team facilitator and members of the team.Â In this step, a team facilitator will be designated who will work with the leadership to launch a project charter that will guide the team in managing the scope of the project and in implementing changes that are linked to the root causes identified in the RCA process. Also, team members will be selected who are familiar with the systems and processes involved in the problem.
- Describe the incident. In this step, facts surrounding the problem will be collected and organized, on why the organization fails to do quality reporting measures. The preliminary information gathered in step 1 will be shared and discussed with the team.
- Identify contributing factors.Â The knowledge gained in step 3 will be used to dig deeper into what happened and why it happened. Also in this step, the conditions, circumstances and situations that caused the organization not to be able to report will be identified. A thorough investigation of the organization’s current data systems and the processes from patient data capture to electronic reporting will be carried out to determine any lacking or faulty process that have resulted to the incomplete generation of data.
- Identify the root causes. The contributing factors will be examined to find the root cause of the problem. In the given scenario, there could be many underlying reasons that had caused the organization’s failure to report. Contributing factors could be due to (a) incomplete data as mentioned, (b) failure of systems to communicate, (c) poor data quality, (d) lack of data standards. These contributing factors are interrelated to each other to significantly affect the interoperability of systems. Identifying the root cause should be dug deeper by asking repeated “why” questions of the contributing factors.
- Eliminate the root causes. This step will also include the design and implementation of changes to eliminate the root cause and to reduce and or prevent the recurrence of the same event in the future. If there are multiple root causes, there will be corrective actions to address each root cause. In the given scenario, the failure to report could probably be due to lack of interoperability or failure of systems to communicate due to poor data quality as manifested by incomplete data generated by the organization’s system. This problem could be addressed by improving patient data capture and by developing an efficient data dictionary. Data integration would probably be needed to cleanse all dirty data, and as well as to employ data standards to improve clinical documentation,Â and data interchange standards to enable the systems to achieve full interoperability and be able to exchange and integrate data among healthcare applications in a state , regional and nationwide level.
- Evaluate and measure. In this step, the success or improvement of actions will be evaluated and measured and will be monitored overtime.
Center for Medicare and Medicaid Services (CMS) (n.d.). Guidance for performing root cause analysis (RCA) with performance improvement projects.Â Retrieved February 20, 2017 from https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/guidanceforrca.pdf
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