Part Five: Getting QAPI Ready — Systematic Analysis and Systemic Action

Once you have a team working on a performance improvement project (PIPs) it’s vital to get to the root of that problem through systematic analysis and systemic action. By using root cause analysis (RCA) you will gain a structure for evaluating events and the ability to focus on the underlying breakdowns in systems or processes. Through this systematic approach you will be able to fully understand the problem and its causes. When using RCA we understand it can be challenging to define the problem or event in a manner that it is not too broad. The QAPI News Brief outlines a few steps of root cause analysis:

– Describe in detail the event so everyone can understand the steps that occurred and where decisions were being made.
–  Look for root causes and their preceding factors as well as any contributing factors that added to the likelihood of the problem becoming an event.
–  Sort identified gaps or breakdowns into categories: human factors, rules, policies or procedure, environment/equipment and barriers.
–  Identify corrective actions and put a plan in place to measure the impact of these interventions.

Identifying the root cause is only the first step. Next, you will need to make changes or corrective actions that can be implemented at the system level throughout your facility. These corrective actions should offer long term solutions to the problem, target the elimination of the root causes and be achievable, objective and measureable.

We hope you enjoyed this series. Want to learn more? Check out how Pathway Health can help your organization prepare for QAPI through our upcoming  QAPI webinar.