Root Cause Analysis in Aging Services: Considerations for Success

Federal regulations for skilled nursing facilities (SNFs) require provider organizations to conduct quality assurance and performance improvement (QAPI) activities that include processes such as root cause analysis (RCA). However, these regulatory trends also affect other parts of the aging services continuum, including assisted living facilities, and areas such as home health, hospice, and Programs of All-Inclusive Care for the Elderly, as more states include continuous quality improvement requirements for licensing.

RCA is a powerful systems analysis tool that informs performance improvement, drives purposeful change to prevent harm, and improves outcomes for all stakeholders. With a focus on organization-wide system improvements, it also operationalizes stronger care and service delivery processes, which helps to ensure better financial sustainability. However, RCAs are not without their own challenges. Individuals conducting RCAs are often apt to focus on immediate causes of a single incident, which essentially leaves latent conditions unrecognized and creates an environment conducive for reoccurrence. Such issues related to RCAs—including those related to scope and focus of the investigation, to safeguarding against the influence of bias, to lack of implementation plans for performance improvement—often affect the success of this time- and resource-heavy QAPI process—a tool that many aging services organizations may hesitate to utilize for fear of legal repercussions.

To combat these difficulties, ECRI has helped analyze more than 750 RCAs from aging services organizations over the last decade that have ranged in focus from resident care issues (e.g., pressure injuries, falls, medication events, wandering and elopement) and staffing issues (e.g., scheduling, competency, adequate coverage), to issues rooted in scope of service (i.e., resident needs fall outside the service line or level of care). Using a systems thinking approach to the RCA process (see What Is Systems Thinking?) acknowledges the importance of organization culture and a culture of safety over individual blame, which enhances resiliency and the effectiveness in preventing adverse incidents from occurring.

This white paper provides a general overview of how to address common challenges with conducting RCAs in aging services settings. It discusses the nature of root causes, reviews the RCA2 model, details common barriers...