Cooper: Root cause analyses hurt

Regulations, whether through government, professional bodies or private ruling entities, can be a pain. Health care, my industry, is near the top — if not over the top — with regulation.

Regulations, whether through government, professional bodies or private ruling entities, can be a pain. Health care, my industry, is near the top — if not over the top — with regulation.

Skilled Nursing Facilities (SNFs) were identified at one time as the most highly regulated industry next to nuclear plants. I have found very few in health care who complain at least to me about standards for safety, quality and patient rights. We’ve also come to understand that certain unsavory practices of so called professionals who gamed the system for their financial benefit have resulted in billing and reimbursement regulations that plague rule-abiding organizations and professionals.

What I find confounding are the regulations developed by people with particularly large left brains who make rules intended to prove accountability. An example is assessment tools that have been standardized so much that the care provider is required to ask questions in a certain order usually using a computer to input answers that are later sent to left brain government workers who calculate it for payment.

One outcome of this practice is that eye contact that brings comfort and professional intuition has been hijacked by left brain linear fact processing.

Then, of course, it’s all done in an environment of ever-increasing productivity, which is really annoying.

I expect it to get worse before it gets better as health care moves to being paid for outcomes and not paid for poor outcomes that were preventable. At this point, I am not sure how it will work, but it seems to be an evolutionary step in turning our current costly reimbursement system “fee for service” on its head.


Getting to the root of the problem

What I do know is that the vast majority of health care professionals – at least 99 percent — want their patient to get well or be comfortable if getting well is not possible. A preventable or unexpected adverse outcome is cause for great despondency in the profession.

The most well-known examples are people who had the wrong leg amputated or the person who died in surgery when a toxic fluid was administered instead of anesthesia or a child who died when the wrong medication dose was given by the nurse or the person who died when given the wrong blood type transfusion.

We can have comfort that these examples are rare and becoming harder to repeat in part due to a process called “root cause analysis” that is required as part of quality programs in hospitals.

I know the term brings to mind root canals, one of the most dreaded dental procedures. A “root cause analysis” is similar in that it literally requires drilling to the root of the cause and exposing the weakness of the system that led to a person paying an enormous price in limb or life.

The analogy fits equally well for those who participate in the process that requires deep institutional soul searching in order to be factually honest, without bias or blinders and totally open to the right answer. It is painful and often shameful.

The forgiving part is that the process recognizes that most adverse outcomes are the result of a system problem rather than a human error of one individual. Painful “root cause analyses” have resulted in significant quality and safety improvements in hospitals.


Drilling down on broken systems

Recent events have brought me to the conclusion that “root cause analysis” should be done in other fields as well. I saw the news clip in which the judge heaped boatloads of shame upon the teachers who cheated on tests. They shouldn’t have done it but I, among many of you, know that we ought to be examining how and why this happened.

I don’t think students died or lost limbs but they lost something essential to their well-being which is a proper education. My guess is that teachers are as annoyed by having to teach to a test developed by another large left brain as I am about sterile assessment forms. “Cheating parties” may have belied the desperation these school teachers felt in an environment of declining public school support. Community leaders and remaining professionals of that school district should be gathering to do a “root cause analysis.”


Exposing the root

Perhaps even more pressing is the clear need to drill down to the infected roots that are driving the incidents of police shootings of black men. Sane and reasonable people need to get together and figure this out. The Justice Department did a drill down on Ferguson, Mo., and reported the prevailing method of filling the city coffers was to catch poor, mostly black people in some sort of act for which they could be fined.

Good to know, I suppose, but not enough to explain those incidents in which fleeing black men were shot and killed or beaten enough to cause serious injury. What is the root cause of violent police responses?

A beloved relative, who was a police officer and now teaches law enforcement, is mortified by any view that suggests police on the whole are prejudiced and violent. I agree with her, but the fact is something in the system is allowing those that are to kill people.

The three-legged stool of education, health care and public safety that supports a thriving, healthy and safe community is teetering and needs concrete stabilization. Instead, too many elected officials politicize these problems and successfully avoid any fixes.

I’ve concluded that entrenched inaction needs to be pulled out by the roots to make room for real solutions.

 

Bertha D. Cooper is retired from a 40-plus year career as a health care administrator focusing on the delivery system as a whole. She still does occasional consulting. She is a featured columnist at the Sequim Gazette. Reach her at columnists@sequimgazette.com.

 

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