Facility-Level Root Cause Analysis

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* 1. Enter the name of your facility.

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* 2. Enter your facility's 6-digit CMS Certification Number (CCN).

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* 3. Enter the name and contact information of the person submitting this RCA.

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* 4. Names of all facility staff involved in this RCA? (Please provide name and role/title)

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* 5. Does your facility routinely provide patient education and engagement surrounding the topic of dialysis adequacy?

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* 6. Which staff member in your facility is the PRIMARY person who educates patients on Kt/V?

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* 7. Please provide a description of the patient education and engagement provided by your facility staff/adequacy management team.

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* 8. Does your facility routinely cut/shorten patients' treatment time when patients are late for scheduled treatment?

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* 9. Of the following root causes, on a scale of 1 (most frequent cause) to 6 (least frequent cause) please rank what you believe to be the most common root causes for poor hemodialysis adequacy outcomes at your facility.

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* 10. What are the specific patient-related factors that contribute to poor Kt/V performance at your facility?  (Select all that apply)

  Greatest Contributing Factor Average Contributing Factor Least Contributing Factor Not Applicable N/A
Shortened Treatments
Missed Treatments
Patient Refusal/Resistance to Permanent Access
Large Interdialytc Weight Gains
Lack of knowledge regarding how he/she contributes to dialysis adequacy

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* 11. For each contributing patient-related factor for poor adequacy outcomes please use the "5 Whys" method to determine the cause(s) of the above-selected contributing factors. (Ex. Patients often miss treatments due to unreliable transportation.)

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* 12. What are the specific access-related factors that contribute to poor Kt/V performance at your facility? (Please select all that apply)

  Greatest Contributing Factor Average Contributing Factor Least Contributing Factor Not Applicable N/A
Delay to vascular surgery
Delayed fistula maturation
Suboptimal blood flow rate
Resistance to permanent access
Cannulation technique 
Long-term catheter in place

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* 13. For each contributing access-related factor for poor adequacy outcomes please use the "5 Whys" method to determine the cause(s) of the above-selected contributing factors. (Ex. Two patients in my facility have long-term CVCs because they have cancelled their appointments because they either cannot afford the copayment or the local vascular surgeon does not accept patient's insurance.)

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* 14. What are the specific staff-related factors that contribute to poor Kt/V performance at your facility?

  Greatest Contributing Factor Average Contributing Factor Least Contributing Factor Not Applicable N/A
Cannulation Technique/Inexperienced Cannulators
Inconsistent or inadequate staff training
Ensuring treatment is delivered as ordered by physician
Missing Pre- and/or Post-BUN Draw
Lack of knowledge/failure to follow lab draw procedure for BUN sampling and spinning

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* 15. For each contributing staff-related factor for poor adequacy outcomes please use the "5 Whys" method to determine the cause(s) of the above-selected contributing factors.

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* 16. What are the specific prescription-related factors that contribute to poor Kt/V performance at your facility? (Please select all that apply)

  Greatest Contributing Factor Average Contributing Factor Least Contributing Factor Not Applicable N/A
Low Blood Flow Rate
Decreased Treatment Time (Especially beginning dialysis with too short treatment time)
Wrong Dialyzer Size
Needle Size (Small needle gauge)

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* 17. For each contributing prescription-related factor for poor adequacy outcomes please use the "5 Whys" method to determine the cause(s) of the above-selected contributing factors.

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* 18. What are specific policy-related factors that contribute to the poor Kt/V performance at your facility? (Please select all that apply)

  Greatest Contributing Factor Average Contributing Factor Least Contributing Factor Not Applicable N/A
Facility's policy regarding shortened treatments when a patient is late
Inadequate Continuous Quality Improvement  program in place

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* 19. For each contributing policy-related factor that contribute to poor adequacy outcomes at your facility please use the "5 Whys" method to determine the cause(s) of the above-selected contributing factors.

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* 20. What are specific equipment-related factors that contribute to poor adequacy performance at your facility? (Please select all that apply)

  Greatest Contributing Factor Average Contributing Factor Least Contributing Factor Not Applicable N/A
Dialyzer Size
Needle Size

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* 21. For each contributing equipment-related factor for poor adequacy outcomes please use the "5 Whys" method to determine the cause(s) of the above-selected contributing factors.

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* 22. Please provide any additional root cause(s) not mentioned above that might be driving poor Kt/V performance at your facility.

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* 23. How long did it take you to complete the RCA?

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* 24. Is your facility currently involved in an internal/organizational QIP or Kt/V initiative?  If yes, please provide a brief description of the initiative in the comment box.

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* 25. I, or another member of my facility's adequacy management team, will be available by phone to review with the Network my facility's RCA on one of the following days between the hours of 10 AM and 2:15 PM:  Tuesday, February 7; Wednesday, February 8; or Thursday, February 9.

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* 26. Did you find this RCA tool to be easy to understand and use?

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