Nearly overnight health care providers were forced to dramatically change how they did business, and how they took care of people. As a result, some practices that were part of the culture of the organization were pushed to the back burner solely out of necessity. There simply was not enough time to do some of the things providers used to do. One thing that appears to have taken a back seat for many providers is the root cause analysis process.
A requirement of nearly every Corporate Integrity Agreement over the last 10 years is for the provider to develop and implement a robust root cause analysis process; this is a pretty clear indication the federal government sees a lot of value in root cause analysis, yet many providers still don’t actively utilize root cause analysis when something happens. The rationale I hear for why root cause analysis is not done on a regular basis is the common refrain “we just don’t have the time.” The pandemic certainly put additional pressure on already strained staff, but the time it takes to develop and implement a meaningful root cause analysis process could pay huge dividends.
When we look at how or why something happened it is human nature to stop at what I call the “first logical conclusion” which typically points the finger at someone who didn’t do what they had been trained to do. The problem is that when we stop there, we never really learn why the bad thing happened. Rarely is it really a people issue, rather it is almost always a process issue. Where did the process fail such that the person did what they did? Was the training accurate and relevant? Was the employee asked to care for too many residents/clients and as a result cut corners in order to save time? These are just a few examples of questions that can be asked during a root cause analysis. Once a team understands the process, and becomes adept at asking the right questions, it actually takes very little time to get to the root cause of the issue which allows changes to be made in the process to prevent a similar failure in the future.
The world of health care moves pretty darn fast. Don’t let that fast pace tempt you to cut corners and not take advantage of a robust root cause analysis process.
Most business leaders get frustrated when employees don’t do the right thing. You shouldn’t have to convince people to do what is right. MCA builds a compliance program and a culture where employees to the right thing, the right way, at the right time so you can focus on taking care of the people you serve.
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Midwest Compliance Associates
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