QAPI Program Utilization_Manual

ROOT CAUSE ANALYSIS PURPOSE: To gather, prioritize and analyze relevant data about events that have or may have adverse effects on the delivery of quality patient care. To identify those causative issues, systems or processes that represent core reasons for occurrence of the event. To develop an action plan that will prevent recurrence of the event. To implement the action plan, monitoring the plan’s effectiveness periodically to assure sustained improvement. POLICY: In response to a sentinel event occurrence, the Director of Performance Improvement will establish an ad hoc Event Analysis Subcommittee to conduct a root cause analysis. The Event Analysis Subcommittee membership is reflective of all levels of the organization and is composed of at least representatives from each of the disciplines as well as a representative of the Agency’s leadership, i.e., Director of Nursing, Clinical Manager , Administrator, Corporate Compliance Officer. PROCEDURE: A root cause analysis contains the following characteristics: Primarily focuses on systems and processes, not individual performance/personnel failures or errors Utilizes accepted, standardized performance improvement tools Progresses from special cause process focus to common cause system and/or organizational focus Consistently focuses on basic, core rationale for causative factor(s) Identifies necessary redesign efforts and/or revisions in systems and processes, intended to improve performance levels and reduce the risk of event recurrence The Event Analysis Subcommittee may request input from individuals with specific expertise relative to the matter under consideration/who have first-hand knowledge of the incident and/or the processes involved in the incident. 82