Linking Medical Education and Hospital Operations Through Trainee Conducted Root Cause Analysis of 30-Day Readmissons

Background:

Transitions out of the hospital and into the next setting of care are a vulnerable time for patients and caregivers.  Targeted process improvement efforts to facilitate safe, efficient and effective transitions can reduce the chance of unnecessary readmission and improve the patient experience.  Systematic review of readmission cases through root cause analysis (RCA) is a tool that can highlight system level vulnerabilities and focus improvement efforts.  The Accreditation Council for Graduate Medical Education has put an increasing focus on engaging trainees in the improvement activities of their training institution through programs such as the Clinical Learning Environment Review.  Trainee conducted RCAs of readmission data presents an opportunity to meet mutual goals of medical education in systems based practice and quality improvement (QI) in transitions of care.

Purpose:

We created a root cause analysis educational workshop for trainees and linked the trainee-generated findings directly to hospital operations. Our goals in doing this were three-fold–1) developing an RCA skillset for trainees, 2) identifying areas for process improvement and 3) engaging trainees in local improvement efforts.

Description:

Internal medicine residents completed a 4-hour workshop during an ambulatory rotation.  During the first hour, participants worked through an Institute for Healthcare Improvement module on RCA.  Next, trainees were presented with their own 30-day all cause readmission cases from a previous inpatient rotation.  They reviewed each case via a guided chart review and then formed teams to conduct a formal root cause analysis on a single case felt to be potentially preventable.  Each team created a fishbone diagram, causal statements and action items based on the case. These were compiled and presented by trainees to the local hospital readmissions committee meeting, a multidisciplinary group that reviews performance data and leads improvement efforts.

30 residents participated in the workshop.  Cases ranged from 1-14 readmissions for each trainee.  Overall, they reviewed 194 cases from 2012-2014 from which they performed 7 formal RCAs.  These were presented at a monthly hospital readmission committee and led to 3 discrete system level changes based on trainee recommendations. 50% of participants completed a post workshop survey.  Of those, 100% felt that reviewing their own readmissions data was a valuable exercise and 87% felt confident on how to conduct a root cause analysis after the workshop.  One commenter stated, “This [workshop] challenged me to think critically about my own actions and system level issues as they relate to readmissions. More importantly, by actively developing recommendations to improve in the future, it helped me feel as though I was part of the solution rather than the problem.”

Conclusions:

Trainee conducted RCA of their own data is a powerful tool for systems level change that can meet mutually enforcing goals of residency education and quality improvement.