During a recent visit to a skilled nursing facility, a nurse made an insightful comment that stuck with me: “You can’t unscramble eggs.” This simple yet profound statement highlighted the difficulty of trying to fix broken systems and processes after issues have already occurred, particularly when it comes to interdisciplinary teamwork. Fortunately, there’s a way to prevent this from happening in the first place: Root cause analysis (RCA). 

While it’s often used to investigate clinical incidents and adverse events, RCA is just as effective for identifying and addressing the systemic issues that hinder teamwork. By integrating RCA into the daily workflow, facilities can address the root causes of breakdowns in interdisciplinary communication and collaboration before they snowball into larger problems.

So, what is root cause analysis?

It is a problem-solving method used to pinpoint the underlying causes of issues, rather than merely treating the symptoms. In healthcare, RCA is typically used after incidents like falls or medication errors, but it can also be applied to improve teamwork, reduce inefficiencies and enhance the overall quality of care. The goal of RCA is to prevent issues from recurring by addressing the core factors that contribute to them.

RCA follows a structured, systematic process that includes several key steps:

  1. Define the problem: Identify what the issue is. This might be a breakdown in communication, recurring patient falls or coding discrepancies.
  2. Gather data: Collect relevant information, such as meeting notes, reports, observations and staff feedback. This step helps clarify when, where and how the issue is occurring.
  3. Identify the root cause: Using techniques like the “5 Whys” or Fishbone Diagrams, determine the underlying reasons why the problem exists. The focus should be on processes and systems, not individuals.
  4. Develop and implement solutions: Once the root cause is identified, create practical, sustainable solutions to address the issue. Solutions should aim to prevent the problem from recurring.
  5. Monitor and evaluate: After implementing changes, track progress over time to ensure the solution is working and the problem has been resolved.

So how can teams integrate RCA into existing systems without creating additional work? 

RCA may sound complex, but it can easily be incorporated into the processes that skilled nursing facilities already use. It doesn’t need to add extra work but rather enhance current systems to better address underlying issues. 

Consider the following options.

  1. Add RCA to regular meetings. Most facilities already hold interdisciplinary care meetings. RCA can be added as a standing agenda item, where teams discuss any recent challenges and collaboratively identify their root causes. A few key questions, such as “Why do we think this problem is occurring?” or “How can we prevent this from happening again?” can easily shift the focus toward RCA.
  2. Incorporate RCA into incident reports. It is already a logical extension of incident reporting. When investigating falls or other adverse events, teams can use RCA to dig deeper into why the incident happened rather than just documenting what occurred. For instance, did a patient fall due to poor lighting, a medication side effect, or inadequate supervision? RCA helps identify the real reason, leading to targeted interventions.
  3. Leverage existing Quality Assurance processes. Facilities are required to have QA programs in place. RCA can be integrated into this system by using it during regular QA reviews. This way, when issues arise — whether in patient care or operational processes — it allows the team to apply RCA to find long term solutions.
  4. Use technology to track RCA progress. Many facilities use electronic health records or other digital tools to monitor patient outcomes. These systems can easily be adapted to include tracking RCA findings and solutions, ensuring the process stays streamlined and data-driven.

Finally, RCA has far-reaching applications in skilled nursing facilities. Here are two examples that show how RCA can be applied to everyday issues that healthcare teams face:

Example 1: Identifying the cause of a resident’s falls

Falls are a common concern in skilled nursing facilities, and RCA can be used to determine why a particular resident is falling repeatedly. In one case, a team used RCA to investigate falls that were occurring at night. After gathering data, the team identified that the root cause was a combination of medication side effects and insufficient nighttime supervision. 

By adjusting the resident’s medication schedule and increasing nighttime staff checks, the team was able to significantly reduce fall risk. This example shows how RCA can target and resolve specific safety concerns.

Example 2: Improving MDS coding accuracy

MDS coding accuracy is essential for reimbursement and care planning, but discrepancies often arise due to communication gaps between departments. In one facility, RCA was used to identify why MDS codes weren’t reflecting the correct therapy complexities and diagnoses. After reviewing data and conducting interviews, the team found that therapists and the MDS coordinator weren’t meeting regularly to discuss patient progress. 

To fix this, the team implemented weekly check-ins, where staff reviewed therapy notes and updated MDS coding together. This small change improved coding accuracy and care planning.

In closing, while “you can’t unscramble eggs,” you can use RCA to ensure that interdisciplinary teamwork doesn’t get scrambled in the first place. By addressing the underlying causes of communication breakdowns, operational inefficiencies, or patient safety concerns, RCA can prevent problems before they escalate. The process doesn’t need to be complex or time-consuming; it’s about improving existing practices to make them more effective.

RCA is a tool that helps teams shift from reacting to problems to preventing them, enhancing both care quality and team cohesion in the process. Skilled nursing facilities that adopt RCA as part of their routine processes can expect not only smoother collaboration but also better patient outcomes and a more empowered staff.

Renee Kinder, MS, CCC-SLP, RAC-CT, serves as the Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she contributes her expertise as a member of the American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, the University of Kentucky College of Medicine community faculty, and an advisor to the American Medical Association’s (AMA) Current Procedural Terminology CPT® Editorial Panel, and a member of the AMA Digital Medicine Payment Advisory Group. For further inquiries, she can be contacted here.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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