Root-cause analysis requires multiple steps

A root-cause analysis (RCA) is a complex tool that requires professional training, but an ED manager can utilize it with the help of an expert, says Kenneth A. Hirsch, MD, PhD, a practicing psychiatrist and director of Medical Risk Management Associates, a consulting firm in Honolulu.

Hirsch provides this highly simplified example of how an RCA might be employed to help reduce overcrowding and long wait times in the ED: The analysis team compiles a detailed sequence of events for each type of patient coming in to the ED — walk-ins, referrals, ambulance arrivals, etc. — with flowcharts.

For each of those patients, the entire process of arrival, registration, triage, treatment, and disposition is broken down into its component parts. Each of those components is then documented in great detail.

"After you have the sequence of events for that component written out, then each member of the team should go to the ED and walk through that process," Hirsch says.

"You write down every single thing you do as you go through that process, and you will find that if you had 15 steps written down, you actually will go through a whole lot more," he continues. "Do I go to that window next, or that window over there?"

All of the questions and uncertainties you identify that the patient faces in the walk through are potential choke points in the system, Hirsch says.

The team members also can carry tape recorders with them as they walk through the process and document in real time their thoughts as they go through the same steps that patients face.

"Do I go right or left here? The signage is bad," Hirsch gives as an example. "I’m standing at the privacy line waiting for the next window to open, but I don’t know if I can go to the next available window or if I’m in line for just this window here."

Discovering issues and addressing them

The entire RCA will proceed in a similar fashion and break down even what seems like the simplest step or procedure into its components and try to account for human nature in the process, Hirsch says. The entire system is analyzed from each participant’s point of view, not just the patient’s.

In the end, the analysis should reveal redundancies, unnecessary steps, potential time delays, and other flaws in the system. The RCA includes many other steps as well, including brainstorming among all participants in the process.

"That’s the kind of specificity that a root-cause analysis can offer," Hirsch explains. "You can look at the choke points and ask why you need this step or this policy. It’s an opportunity to find the issues that you never dreamed about, much less knew how to fix."