Root Cause Analysis (RCA) is a systematic and structured process used to identify the root causes that results in an undesirable outcome or adverse event and to develop corrective actions. The goal of RCA is not just to treat the symptoms of a problem but to delve into the underlying causes of the failure. By understanding these causes, a hospice agency can develop strategies to mitigate risks and implement corrective actions to prevent future occurrences. This approach to addressing adverse events will lead to improved patient safety and enhanced quality of care. Further, by promoting a culture of safety, RCA fosters a culture of transparency, accountability, and continuous improvement in the hospice agency.
When is root cause analysis used
A hospice agency can use root cause analysis to investigate any unexpected occurrences such as hospice acquired pressure ulcers, medication errors, or process variations where recurrence could result in serious adverse outcomes. Candidates for RCA may be identified via patient satisfaction surveys, incident reports, surveys, or other reports and audit activities. A root cause analysis focuses on systems and processes, rather than individuals in the agency. The objective of the RCA is to reduce the risk of recurrence by identifying opportunities to improve or redesign systems or processes. By implementing system changes, this will lead to sustained system improvement.
Elements of root cause analysis
A comprehensive root cause analysis includes the following elements:
Problem identification: Identify the adverse event to be investigated and gather preliminary information. Events and issues can come from many sources such as patients and their families, staff, or regulatory bodies. The agency should have a process for deciding what events are selected for RCA.
Define the event: Clearly describe the adverse event, error, or near miss. Include specifics such as what happened, where, when, and who was involved.
Gather initial data: Collect all relevant information about the event including incident reports, patient records, and witness statements.
Assemble RCA team: Select the members of the RCA team and the team facilitator. Team members should be knowledgeable about the processes and systems that they will be investigating.
Multidisciplinary team: Form a team that includes individuals with diverse expertise and perspectives. This may include clinicians, administrators, and support staff.
Assign roles and responsibilities: Clearly define the roles and responsibilities of each team member to ensure an organized and effective RCA process.
Data collection and investigation: Collect and organize the facts about the adverse event that will be investigated.
Detailed event timeline: Create a detailed timeline of events leading up to, during, and after the incident. This helps in understanding the sequence of events.
Conduct interviews: Interview staff involved in the event to gain insights into what happened and why. Ensure a non-punitive approach to encourage open and honest communication. Review documentation: Examine all relevant documentation including patient records, policy and procedure manuals, and any relevant logs.
Identify contributing factors and root causes: Identify the situation, circumstances, or conditions that increased the likelihood of the adverse event. Conduct a thorough analysis of contributing factors that lead to identification of underlying process and system issues.
Cause and effect analysis: Use tools such as fishbone diagrams (Ishikawa) or flow charts to map out the possible causes and identify the root causes. Five whys technique: Ask “why” repeatedly (usually five times) to drill down to the underlying root cause(s) of the problem.
Develop action plan: Develop plan for best changing the processes and systems to reduce the likelihood of another similar event. Design and implement changes to eliminate the root causes. This may involve creating new processes.
Corrective actions: Develop specific, measurable, achievable, relevant, and timebound (SMART) corrective actions to address the root causes.
Assign responsibility: Assign responsibility for implementing each corrective action to specific individuals or teams. Timeline: Establish a timeline for the implementation of each corrective action
Implementation and Monitoring: Implement the plan and evaluate its performance. Create mechanisms to gather data that can be used to measure the success of changes that were introduced.
Implement changes: Put the corrective actions into practice. Ensure that staff are trained and aware of changes to procedures or policies. Monitor effectiveness: Continuously monitor the effectiveness of the corrective actions. This may involve regular audits, follow up assessments, and a feedback mechanism.
Documentation and Reporting: Create documentation of the RCA process including all findings, root causes, and corrective actions taken. Share findings with stakeholders, promoting a culture of transparency.
Detailed Reports: Document the entire RCA process, including findings, root causes, corrective actions, and implementation outcomes.
Communicate findings: Share the RCA findings and action plans with all stakeholders including staff, patients, and regulatory bodies.
Continuous improvement: Review the RCA process on a periodic basis to identify any necessary modifications or areas that could benefit from improvement. Continuous improvement ensures that the agency promotes a culture of growth and continuous learning.
Review and revise: periodically review the RCA process and outcomes to ensure sustained improvements. Revise strategies as necessary based on new data and feedback.
Promote a learning culture: Foster an environment where continuous learning and improvement are encouraged and staff feel empowered to report issues and participate in problem solving.
Root cause analysis is a vital tool in hospice care for understanding and addressing the underlying causes of adverse events and errors. By systematically identifying and correcting these root causes, hospice agencies can significantly enhance patient safety, improve quality of care, and promote a culture of continuous improvement. A well-executed RCA resolves the immediate issue and provides valuable insights to prevent future occurrences, thereby ensuring better outcomes for patients and their families.
People with terminal illness experience pain at the end of life and for many, this pain goes untreated. One of the key elements of hospice care is effectively managing the patient’s pain. Untreated or undertreated pain results in needless suffering – due to physical pain and mental distress. However, family caregivers often have a difficult time assessing their loved one’s pain. Further, they are often concerned with side effects of pain medications, including concerns of addiction to or tolerance of pain medications. Further, both patients and family caregivers often have trouble communication with the hospice team the degree and nature of pain that the patient is experiencing. This often leads to ineffective pain management and needless suffering in end-of-life.
What are some considerations when giving pain medication?
Respect
Respect the patient’s wishes regarding pain management. Understanding a patient’s goals and values guides the care team in providing personalized and compassionate care.
Consult
Pain medication decisions are made in consultation with the patient, considering their preferences, values, and goals for care.
Collaborate
The hospice team includes the primary physician, medical director, nurse, social worker, chaplain, hospice aide, caregivers, and patient. Everyone works together to create the right plan.
How should pain medication be administered and monitored?
Individualized and Regular Assessment
Pain medicine is administered based on individualized assessments of the patient’s pain levels. Regular assessments of pain are important for managing pain and ensuring the plan remains effective.
Address pain early
Addressing pain before it becomes too severe can contribute to more effective pain control and improved quality of life.
Communication
Encourage patients to communicate openly about their pain levels. This information is crucial for healthcare providers to make informed decisions about medication adjustments. Regular communication between caregivers and healthcare providers ensures an accurate understanding about the patient’s pain.
Low dose pain medicine
It is preferable to initiate low-dose medication to maintain alertness and minimize potential side effects.
Titration
Titrate pain medication up as needed, to achieve optimal pain relief. Regular assessments guide the titration process ensuring the right balance between pain control and functionality. Often a long-acting pain medication is given coupled with a breakthrough pain medication, if needed, to keep pain at or below goal level.
Timely administration
Administer pain medicine in a timely manner, adhering to the prescribed schedule. Consistent dosing helps maintain a baseline level of comfort.
Pain log
Use a pain log to track pain levels, related factors, what medicine was given, dosage of medication, and time medication was given.
Education
The hospice team should educate the patient and caregivers on the use of pain medication, including dosage, timing, and potential side effects.
Monitor
Monitor for potential side effects of pain medication and collaborate with the healthcare team to address any concerns. This includes a careful assessment of the patient’s overall well being.
Consider a holistic approach to pain management
Many hospice agencies advocate for a holistic approach to pain management, including physical, emotional, and spiritual care. Alongside pain medications, this involves exploring and integrating non-pharmacological interventions such as massage, music therapy, aromatherapy, and relaxation techniques for a more comprehensive approach to pain relief.
The Affordable Care Act authorized the establishment of a Quality Reporting Program for hospices. The Hospice Quality Reporting Program (HQRP) was established in 2014. HQRP aims to ensure that the level of quality in clinical care, symptom management, and patient and family experiences is at a high level across all hospice agencies. HQRP further aims to help patients and their families make informed decisions about end-of-life care. The measures and benchmarks reported in HQRP also provide CMS with measurements of hospice agency performance and how agencies are performing relative to other agencies in their region and across the nation. Some of the measures can also be used as indicators of Medicare fraud or abuse.
The Affordable Care Act also requires that quality measures relating to hospice care are reported on a CMS website.
HQRP data collection began in 2014 with two components. The first component was related to Hospice Item Set (HIS) data collection and transmission. The second component was related to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey participation.
The Hospice Compare website was launched in 2017, enabling patients and their families to compare between the performance of different hospice agencies. In December 2020, Hospice Compare was replaced by Care Compare.
Which measures are included in HQRP?
HQRP measures care across a patient’s hospice stay. With a commitment to quality improvement, data transparency, and informed decision-making, the number of HQRP measures has increased since the launch of the program. As of 2022, HQRP includes four metrics, each of which includes several underlying measures:
Performance level is not considered when determining compliance with HQRP; CMS requires a hospice agency to submit data completely, and on time, to be considered compliant. A Medicare-certified hospice agency is HQRP compliant if it submits the required data within the required timeframe and the data is accepted. A hospice agency is not compliant if it submits data but the data is not accepted. Failure to comply with HQRP requirements results in a two percentage point reduction in Annual Payment Update (APU). That is, for a hospice agency to preserve its full payment update, the agency must meet all HQRP data submission requirements. Failure to submit results will also impact an agency’s results on Care Compare.
How does CMS use the data that is submitted?
CMS currently uses the collected data internally for strategic planning purposes. CMS also uses the act of reporting to raise attention and awareness and promote actions to improve patient care.
Can a hospice agency verify its HQRP data before it is publicly published?
A hospice agency can review its HQRP data via the CASPER system before the results are made public on Care Compare. CASPER reports can be accessed by selecting the CASPER Reporting link to the CMS Quality Improvement and Evaluation System (QIES) Systems for Providers webpage. Hospice-specific reports are located in the Hospice Provider and Hospice Quality Reporting Program reporting categories in CASPER. Hospice agencies should review this data before it is published on Care Compare to ensure data accuracy, since the published data is used by the public to compare and select a hospice agency for end-of-life care.
Prior to the third hospice benefit period, and prior to each subsequent benefit period, a hospice physician or nurse practitioner is required to have a face to face encounter with the hospice patient to recertify that the patient continues to be Medicare eligible for hospice benefits. The face to face encounter must occur within 30 calendar days prior to the start of the third benefit period and each subsequent benefit period.
The face to face encounter is necessary to recertify that the patient remains eligible for Medicare hospice benefits. If face to face encounters are not performed timely, the patient is is no longer hospice eligible. The hospice may continue to provide hospice services to the patient but may no longer continue to bill Medicare. Instead, the hospice would need to assume all financial responsibility for the patient until such time that the hospice is able to reestablish patient hospice eligibility. The patient may be readmitted to hospice once hospice eligibility criteria are once again met.
What if there are exceptional circumstances that cause the hospice to be unable to timely complete the face to face encounter?
What are exceptional circumstances?
If a patient is admitted and is in the third benefit period or later, the hospice agency may be unable to perform the face to face encounter prior to the start of the benefit period.
For example, if the patient is an emergency weekend admission and the nurse practitioner or hospice physician is unable to meet with the patient prior to hospice admission. The patient is only seen the following Monday.
Another exceptional circumstance may be where the CMS data system is unavailable and the hospice agency is unaware that the patient is in the third or later benefit period.
In these documented exceptional circumstances, the face to face encounter is considered timely if it is completed within two days after admission.
In addition, if the patient dies within two days of admission, the face to face encounter is considered complete.
A hospice face to face encounter is a step in patient recertification beginning with the third benefit period and each benefit period thereafter. The goal of hospice face to face patient encounter is to encourage greater involvement of the physician in the care of patients who have been on hospice for an extended period of time. These patients will require a face to face visit from the physician or from a hospice nurse practitioner who will determine continued hospice eligibility. The face to face encounter is one part of hospice recertification. As such, the face to face encounter will also occur prior to recertification.
When must a face to face encounter take place?
A face to face encounter must take place within 30 days prior to the start of the patient’s third benefit period. It also must take place within 30 days prior to each subsequent benefit period. The requirement for a face to face encounter considers the patient’s hospice stays across all hospices. For example, if a patient spent 100 days at Hospice Agency A and then switched to Hospice Agency B, Hospice Agency B will need to conduct a face to face encounter within 50-80 days of the patient’s admission. That is, when the patient is admitted to hospice B the days of counting toward the face to face encounter begin from the first day that the patient entered any hospice care.
How will I know if the patient has had prior hospice care?
Upon admitting a patient, the hospice agency should check the Common Working File to determine the patient benefit period and whether a face to face encounter is required.
Who may conduct the face to face encounter?
Either the hospice physician or nurse practitioner (NP) may conduct the face to face encounter. The hospice physician may be an employee or contracted by the hospice agency. If the NP conducts the face to face encounter, the NP must be an employee of the hospice and is not permitted to be a contractor (since nursing is a core service).
What should the recertification narrative include?
The third benefit recertification – and each subsequent recertification – will need to contain clinical findings that support continued hospice eligibility. The narrative must include an explanation of why the clinical findings support a life expectancy of six months or less.
If the physician conducts the face to face, he or she will be responsible to write the narrative about the clinical findings regarding the patient’s condition and for certifying the patient’s continued eligibility for hospice.
If the nurse practitioner conducts the face to face encounter, he or she will report back the clinical findings to the interdisciplinary team as well as to the hospice physician who will certify as to whether the patient is eligible for continued hospice care.
The recertification requires an attestation
The clinician who conducts the face to face encounter must attest in writing that the face to face encounter was performed with the patient and must include the date that the encounter occurred.
If an NP conducts the encounter, the NP must attest that the clinical findings were sent to the certifying physician.
The attestation is signed and dated in is included as a separate and distinct section of the recertification. The recertification also clearly notes the benefit period dates for which the recertification applies.
What happens if the face to face does not take place timely?
If the face to face does not take place, the patient is considered no longer considered terminally ill and therefore is not eligible for the Medicare hospice benefit. The patient remains ineligible until such time that the face to face encounter occurs and it is confirmed that the patient is once again hospice eligible. The patient must be discharged from the hospice but can be readmitted once the face to face encounter occurs. Medicare does permit the hospice agency to continue to provide services at the agency’s expense until the patient’s eligibility is reestablished. However, this care will be provided outside of the Medicare hospice benefit.
Hospice Conditions of Participation – employees versus contractors
Hospice conditions of participation require that almost all hospice core services are delivered by hospice agency employees and may not be delivered by contractors. Hospice core services include:
Nursing services
Social services
Counseling services including spiritual, bereavement and dietary
Physician services
Although physician services are a core service, the regulations permit a hospice agency to contract for physician services.
When may a hospice use contracted staff for core services?
Other than physician services, only under extraordinary circumstances may a hospice agency use contracted staff for core services.
What are extraordinary circumstances?
Under extraordinary circumstances, a hospice may use contracted staff to provide core services. Examples include:
Patient needs unexpectedly exceed the capacity of hospice agency employees, due to unanticipated surge in demand. In this case, contracted staff may be temporarily used to service patients.
Temporary staffing shortages, for example due to illness, result in the inability of the hospice to service patient needs. In this case contracted staff may be used to temporarily supplement hospice agency employees.
A hospice patient travels outside of the hospice agency’s service area. In this case the agency is permitted to contract with another Medicare certified hospice agency to provide services to the patient while the patient is traveling.
