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As Payment Moves to Value, the Circle of Root Causes Expands


Over the past 20 years at HealthInsight, I've had the opportunity to work with health care providers and organizations on root cause analysis to learn from sentinel events, patient harms and other negative, unwanted and unexpected events. Seeking to prevent future harms, we've learned that the most important answers to the question "why did this happen?" – the root causes – are often far removed in time and space from the events that occasioned the review.

Cause and effect analysis is a technique employed in root cause analysis that pushes you to consider all possible causes of a problem, rather than just the ones that are proximal and obvious. Forms of cause and effect analysis include the "5 Whys" and causal tree analysis. Analyses using these techniques produce cause-effect chains, with each identified cause itself becoming the effect of preceding causes. When learning and applying either of these analysis techniques, it's not always clear when the analysis stops, because one can always propose a preceding cause – even if you have to go back to the "big bang."

General advice for a stopping rule is when you've found a cause that:

  • If removed, would prevent (or reduce the likelihood) of future unwanted events, and
  • Is, in some sense, within the control of, or can be influenced by, the organization conducting the analysis.

Such causes are promising candidates to be called "root causes."

There is an interesting result that follows from this type of thinking: if you change what is within the control of an organization, you change the range of what might be called root causes.

The exciting potential in the movement from pay-for-volume to pay-for-value is that it may change the range of factors that are within the control of health care organizations, whether those organizations are hospitals, outpatient practices, home health agencies, skilled nursing or integrated systems of care. Only a certain range of staffing and process models are financially viable in a pay-for-volume environment – in effect, organizations only control factors within this range. Pay-for-value creates a new environment and changes the range of viable models.

Our task is to discover together what is now possible (or will become possible) in the pay-for-value environment. This is no small task. Those of us who have been working in patient safety and health care quality improvement for some time have learned the boundaries and limitations imposed by pay-for-volume incentives. We are at risk for having our thinking anchored in outdated funding models.

In the ongoing process of developing quality and safety strategies, we might need to constantly ask ourselves, "how are changes in the payment environment introducing new options to improve quality and safety?" Indeed, we might even consider revisiting previous root cause analyses or resulting action plans to see if the changing payment environment offers new solutions.

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