RCA - Hospitalizations
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Facility Information
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Facility Process Assessment
Our facility was identified as not maintaining stability or forward progress and are performing an internal root cause analysis to identify the reason sustainability efforts failed on which of the following topics:
Goal 3 and 4 Topics
(Select All That Apply By Clicking in Box)
Were patients involved in conducting this root cause analysis (RCA)?
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No PHI / PII in the following fields.
Examples of PHI include patient name or initials, birthdate, SSN, etc.
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RCA Analysis Tool
Was a standardized tool used to conduct this RCA? (examples: Five Whys, Fishbone. Lean A3)
Barriers: Incident Patients
Which of the following domains best represent the primary barrier to successful performance on the topic?
Please describe in detail the primary barrier and underlying causes to achieving successful performance on the topic.
PDSA Cycle
Plan:
Describe in detail your dialysis facility’s plan for addressing the identified primary barriers inhibiting successful performance on the topic.
Do:
What specific action(s) will your facility take to execute the Plan?
Study:
How will you evaluate that your plan worked?
Are there patients in your facility who may benefit from one-to-one peer mentoring to support avoiding hospitalization?
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WARNING: DO NOT ENTER PHI / PII ON THIS FORM.