Improve DM through root cause analysis

It is especially powerful in prevention efforts

Root cause analysis, long a popular tool for quality improvement initiatives, holds tremendous promise for occupational health professionals seeking to improve their disability management programs, says Jennifer Christian, MD, president and chief medical officer of Webility Corp. in Wayland, MA.

Unfortunately, she adds, while many occ-health professionals are effectively using root cause analysis in other areas of their work, few if any have applied it to disability management.

Root cause analysis entails finding the real cause of a problem and dealing with it, rather than simply continuing to deal with the symptoms.

One of the key questions it poses is: How can we prevent this from happening again?

Why hasn’t root cause analysis made inroads in disability management? "I think disability management is at a pretty primitive level in this country; we’re pretty much in a reactive mode and not focused commonly on prevention," Christian asserts.

Examining its potential in safety programs reveals the opportunities to employ root cause analysis to great benefit, she says.

"It can really become powerful on the prevention side when you start mining every incident for the way it teaches you about how your preventive system is working," Christian explains. "When you stop looking at injuries as failures, but rather as intelligence, you can take it to the next level."

Unfortunately, she adds, the concept of using a disability episode is foreign to most companies. "Most are still in the reactive mode."

Nevertheless, she continues, "In quality management programs in general, when you start to really make a difference is when you begin to understand what the fundamental factors driving your problems are, and when you try to set up a process that will work right — rather than trying to mop up the mess at the other end. I tend to see things as systems."

Real-world examples

Christian first realized the potential of root cause analysis while studying disability data in her previous position as vice president and chief medical officer at ManagedComp Inc. in Waltham, MA.

"For a while, we decided to take a graph sample of claims each month — one week’s worth of lost time injury — and have the field offices do an analysis to explain why that case went to lost time," she recalls.

"It was an amazing process, because generally speaking, nobody had ever asked that question before."

What the process did was to give Christian and her colleagues the ability to classify common themes underlying the injuries, and some ideas as to what could be done to improve the system.

Each of the seven field offices had different systemic problems. "In some areas, we were not teaching the client our system — we were not giving them the tools they needed to be successful," she says. "For example, the supervisor did not have the name of the individual to whom to refer cases."

About 50% of the time, she notes, they discovered the problem lay with the employer and, most commonly, with the first-line supervisor.

"In another case, a company officially had a return-to-work program, but when push came to shove, some supervisors said they couldn’t be bothered," says Christian.

The bottom line, she says, was "We started to figure out we had to put some more meat in more hamburgers."

For example, as a company, ManagedComp was proud of the fact that it referred in network. "We believed, based on our own assessment, that we referred 80% of the cases," Christian observes. "But when we actually looked at the data and developed, through a tremendous amount of hard work, the ability to actually track which doc was intended for each facility to use, the patients actually went to them 30% of the time."

When most companies refer to network penetration, what they’re really talking about is how many of the bills were billed by a doctor who is a member of the discount network, Christian explains. "That’s a lot different than saying the employee was directed where they were supposed to go."

When Christian and her colleagues figured this out, they built up their capability to ensure employees were directed to the right physician.

"We ended up doubling, and almost tripling, the percentage who ended up in network," she reports.

Other applications

There are other areas of disability management where root cause analysis can make a real difference, says Christian.

"The two biggies are getting the employee to the right doctor, and providing transitional work immediately," she says. "When you do a root cause analysis, another thing you discover is not only a failure to offer transitional work, but also slow response time."

In other words, a lot of time is wasted during any given day. "Yes, maybe the case went to lost time; you had a doc willing to sign a release, and an employer willing to provide light duty, but there was an unaccountable slowness in responding. This is flabby management, and it’s hard to defend," says Christian. "A lot of lost dollars could be recovered."

In an effort to help recover some of those dollars, Webility ( now is teaching root cause analysis in its course for supervisors, and trying to advocate for this method of analysis.

"From a QI point of view, you need to get to a new level in the management of a program, where you go beyond telling people what they are supposed to do, and you actually check to see if they are doing what they said they would do," Christian concludes.

[For more information, contact:

Jennifer Christian, MD, President and Chief Medical Officer, Webility Corp., Wayland, MA. Telephone: (508) 358-5218. Web site:]