Element 5: Systematic Analysis and Systemic Action
The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. The facility uses a thorough and highly organized/ structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered. Additionally, facilities will be expected to develop policies and procedures and demonstrate proficiency in the use of Root Cause Analysis. Systemic Actions look comprehensively across all involved systems to prevent future events and promote sustained improvement. This element includes a focus on continual learning and continuous improvement.
QAPI is the merger of two complementary approaches to quality management, Quality Assurance (QA) and Performance Improvement (PI). QA and PI combine to form QAPI, a comprehensive approach to ensuring high quality care. Both involve seeking and using information, but they differ in key ways:
ELEMENT 5 – Systematic Analysis and Systemic ActionGetting to the Root of the Problem (Systematic Analysis)
Root cause analysis (RCA) provides a structure for evaluating events (e.g., adverse event, incident, near miss, unsafe condition, or complaint). The RCA process looks at events and incidents from a systems perspective. RCA avoids focusing on individual performance as a cause of errors or events, and instead focuses on the underlying breakdowns or gaps in the systems or processes in which individuals are working. The key question in RCA is “why?”. The goal of RCA is not to describe what happened, but to understand why things happened or are done a certain way. If the underlying root causes of performance can be identified, changes can be made to improve current performance and prevent future occurrences.
Focus on a specific problem. One of the challenges when you first start using RCA is defining the problem or the event in such a way that it is not too broad. For example, RCA on medication errors will quickly get too big. Instead, identify the various types of medication errors that are occurring and use the RCA process to better understand each type. By looking at several types of medication errors you will start to see common causes or contributing factors that can be addressed with a broader intervention.
Root Cause Analysis is an excellent tool for performance improvement because it helps identify the root causes and contributing factors that led to an event or that if changed can improve performance. However, identifying root causes is only the first step. Next you will need to implement changes or corrective actions at the system level. This will result in improvement or reduce the chance of the event recurring. Often this step is the weakest link in the process, as solutions often center on training/ education or asking clinicians to “be more careful.”
QAPI Five Elements
Element 5 – Systematic Analysis and Systemic Action
Understand and focus on organizational processes and systems
|Guidance for Failure Mode and Effects Analysis (FMEA) Guidance for Root Cause Analysis (RCA) Flowcharting Five Whys Fishbone Diagram