New Shift: Home Dialysis Referral Root Cause Analysis (RCA)

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. 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. Which staff member in your facility is the PRIMARY person who educates patients about home dialysis therapies?

Facility Administrator/Clinic Manager

Medical Director/Physician

Home Therapy Nurse/Home Therapy Nurse Manager

Social Worker

Dietitian

Patient Care Technician

Other (please specify)

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* 6. Please provide a description of the patient education and engagement activities provided by your facility/home dialysis program staff.

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* 7. Was patient(s) input provided for the completion of RCA?

Yes

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* 8. How many patients were involved in completion of RCA?

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* 9. Were any of the patients involved in the completion of the RCA a member of the disparate group?

Yes

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* 10. How many patients of the disparate group were involved in the completion of the RCA?

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* 11. What are the facility- and staff-related factors you believe contribute to low home referral rates in your facility?

	Greatest Contributing Factor	Average Contributing Factor	Least Contributing Factor	N/A
Perception about patient - "Patient is non-compliant"/"Patient is not a good candidate"	Perception about patient - "Patient is non-compliant"/"Patient is not a good candidate" Greatest Contributing Factor	Perception about patient - "Patient is non-compliant"/"Patient is not a good candidate" Average Contributing Factor	Perception about patient - "Patient is non-compliant"/"Patient is not a good candidate" Least Contributing Factor	Perception about patient - "Patient is non-compliant"/"Patient is not a good candidate" N/A
Staff turnover/Not enough home therapy staff	Staff turnover/Not enough home therapy staff Greatest Contributing Factor	Staff turnover/Not enough home therapy staff Average Contributing Factor	Staff turnover/Not enough home therapy staff Least Contributing Factor	Staff turnover/Not enough home therapy staff N/A
Poor or absent home referral process	Poor or absent home referral process Greatest Contributing Factor	Poor or absent home referral process Average Contributing Factor	Poor or absent home referral process Least Contributing Factor	Poor or absent home referral process N/A
Poor or inconsistent home referral tracking and monitoring	Poor or inconsistent home referral tracking and monitoring Greatest Contributing Factor	Poor or inconsistent home referral tracking and monitoring Average Contributing Factor	Poor or inconsistent home referral tracking and monitoring Least Contributing Factor	Poor or inconsistent home referral tracking and monitoring N/A
Low facility leadership/physician support of home therapies	Low facility leadership/physician support of home therapies Greatest Contributing Factor	Low facility leadership/physician support of home therapies Average Contributing Factor	Low facility leadership/physician support of home therapies Least Contributing Factor	Low facility leadership/physician support of home therapies N/A
Staffs' fear of job loss if more patients transition from in-center to home therapy	Staffs' fear of job loss if more patients transition from in-center to home therapy Greatest Contributing Factor	Staffs' fear of job loss if more patients transition from in-center to home therapy Average Contributing Factor	Staffs' fear of job loss if more patients transition from in-center to home therapy Least Contributing Factor	Staffs' fear of job loss if more patients transition from in-center to home therapy N/A
Inadequate staff training and education surrounding home therapies and how to engage patients in discussing/encouraging home therapies	Inadequate staff training and education surrounding home therapies and how to engage patients in discussing/encouraging home therapies Greatest Contributing Factor	Inadequate staff training and education surrounding home therapies and how to engage patients in discussing/encouraging home therapies Average Contributing Factor	Inadequate staff training and education surrounding home therapies and how to engage patients in discussing/encouraging home therapies Least Contributing Factor	Inadequate staff training and education surrounding home therapies and how to engage patients in discussing/encouraging home therapies N/A
Lack of physician/staff follow-up to patient interest	Lack of physician/staff follow-up to patient interest Greatest Contributing Factor	Lack of physician/staff follow-up to patient interest Average Contributing Factor	Lack of physician/staff follow-up to patient interest Least Contributing Factor	Lack of physician/staff follow-up to patient interest N/A
Failure to reproach or too long of delay before reproaching patient after patient declined initial education	Failure to reproach or too long of delay before reproaching patient after patient declined initial education Greatest Contributing Factor	Failure to reproach or too long of delay before reproaching patient after patient declined initial education Average Contributing Factor	Failure to reproach or too long of delay before reproaching patient after patient declined initial education Least Contributing Factor	Failure to reproach or too long of delay before reproaching patient after patient declined initial education N/A
Use of too much medical jargon and acronyms when educating patients on home dialysis therapies	Use of too much medical jargon and acronyms when educating patients on home dialysis therapies Greatest Contributing Factor	Use of too much medical jargon and acronyms when educating patients on home dialysis therapies Average Contributing Factor	Use of too much medical jargon and acronyms when educating patients on home dialysis therapies Least Contributing Factor	Use of too much medical jargon and acronyms when educating patients on home dialysis therapies N/A

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* 12. For each contributing facility- and staff-related factor for home referral barriers, please use the "5 Whys" method to determine the cause(s) of the above-selected contributing factors. If you wish to add additional facility- and staff-related factors, and the causes of those factors please do add them here:

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* 13. What are the patient-related factors you believe contribute to the low home referral rates in your facility?

	Greatest Contributing Factor	Average Contributing Factor	Least Contributing Factor	N/A
Misconceptions about home therapy	Misconceptions about home therapy Greatest Contributing Factor	Misconceptions about home therapy Average Contributing Factor	Misconceptions about home therapy Least Contributing Factor	Misconceptions about home therapy N/A	Misconceptions about home therapy
Lack of pre-dialysis education	Lack of pre-dialysis education Greatest Contributing Factor	Lack of pre-dialysis education Average Contributing Factor	Lack of pre-dialysis education Least Contributing Factor	Lack of pre-dialysis education N/A	Lack of pre-dialysis education
Lack of education once admitted to in-center	Lack of education once admitted to in-center Greatest Contributing Factor	Lack of education once admitted to in-center Average Contributing Factor	Lack of education once admitted to in-center Least Contributing Factor	Lack of education once admitted to in-center N/A	Lack of education once admitted to in-center
Fear of self-cannulation/self-care	Fear of self-cannulation/self-care Greatest Contributing Factor	Fear of self-cannulation/self-care Average Contributing Factor	Fear of self-cannulation/self-care Least Contributing Factor	Fear of self-cannulation/self-care N/A	Fear of self-cannulation/self-care
Lack of family/care partner support (Has family, but does not have the support of family for home therapy)	Lack of family/care partner support (Has family, but does not have the support of family for home therapy) Greatest Contributing Factor	Lack of family/care partner support (Has family, but does not have the support of family for home therapy) Average Contributing Factor	Lack of family/care partner support (Has family, but does not have the support of family for home therapy) Least Contributing Factor	Lack of family/care partner support (Has family, but does not have the support of family for home therapy) N/A	Lack of family/care partner support (Has family, but does not have the support of family for home therapy)
Values the social aspect of in-center hemodialysis over home therapy	Values the social aspect of in-center hemodialysis over home therapy Greatest Contributing Factor	Values the social aspect of in-center hemodialysis over home therapy Average Contributing Factor	Values the social aspect of in-center hemodialysis over home therapy Least Contributing Factor	Values the social aspect of in-center hemodialysis over home therapy N/A	Values the social aspect of in-center hemodialysis over home therapy
Not a viable home therapy candidate for medical or safety reasons	Not a viable home therapy candidate for medical or safety reasons Greatest Contributing Factor	Not a viable home therapy candidate for medical or safety reasons Average Contributing Factor	Not a viable home therapy candidate for medical or safety reasons Least Contributing Factor	Not a viable home therapy candidate for medical or safety reasons N/A	Not a viable home therapy candidate for medical or safety reasons
Misconceptions about the cost of home dialysis	Misconceptions about the cost of home dialysis Greatest Contributing Factor	Misconceptions about the cost of home dialysis Average Contributing Factor	Misconceptions about the cost of home dialysis Least Contributing Factor	Misconceptions about the cost of home dialysis N/A	Misconceptions about the cost of home dialysis
Concerns about body image	Concerns about body image Greatest Contributing Factor	Concerns about body image Average Contributing Factor	Concerns about body image Least Contributing Factor	Concerns about body image N/A	Concerns about body image
Concerns about the amount of supplies needed for home dialysis therapy	Concerns about the amount of supplies needed for home dialysis therapy Greatest Contributing Factor	Concerns about the amount of supplies needed for home dialysis therapy Average Contributing Factor	Concerns about the amount of supplies needed for home dialysis therapy Least Contributing Factor	Concerns about the amount of supplies needed for home dialysis therapy N/A	Concerns about the amount of supplies needed for home dialysis therapy
Socioeconomic: Unstable housing, education, income, etc.	Socioeconomic: Unstable housing, education, income, etc. Greatest Contributing Factor	Socioeconomic: Unstable housing, education, income, etc. Average Contributing Factor	Socioeconomic: Unstable housing, education, income, etc. Least Contributing Factor	Socioeconomic: Unstable housing, education, income, etc. N/A	Socioeconomic: Unstable housing, education, income, etc.
Health Literacy: Communication, comprehension, language, cultural barriers, etc.	Health Literacy: Communication, comprehension, language, cultural barriers, etc. Greatest Contributing Factor	Health Literacy: Communication, comprehension, language, cultural barriers, etc. Average Contributing Factor	Health Literacy: Communication, comprehension, language, cultural barriers, etc. Least Contributing Factor	Health Literacy: Communication, comprehension, language, cultural barriers, etc. N/A	Health Literacy: Communication, comprehension, language, cultural barriers, etc.

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* 14. For each contributing patient-related factor for home referral barriers, please use the "5 Whys" method to determine the cause(s) of the above-selected contributing factors. If you wish to add any additional patient-related factors and the causes of those factors please add them here:

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* 15. What are the policy- and organizational-related factors you believe contribute to low home referral rates in your facility?

	Greatest Contributing Factor	Average Contributing Factor	Least Contributing Factor	N/A
Poor upfront financial incentive	Poor upfront financial incentive Greatest Contributing Factor	Poor upfront financial incentive Average Contributing Factor	Poor upfront financial incentive Least Contributing Factor	Poor upfront financial incentive N/A
Lack of leadership buy-in and support of home therapies	Lack of leadership buy-in and support of home therapies Greatest Contributing Factor	Lack of leadership buy-in and support of home therapies Average Contributing Factor	Lack of leadership buy-in and support of home therapies Least Contributing Factor	Lack of leadership buy-in and support of home therapies N/A
No internal/organizational initiatives for increasing home therapy referral rates	No internal/organizational initiatives for increasing home therapy referral rates Greatest Contributing Factor	No internal/organizational initiatives for increasing home therapy referral rates Average Contributing Factor	No internal/organizational initiatives for increasing home therapy referral rates Least Contributing Factor	No internal/organizational initiatives for increasing home therapy referral rates N/A

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* 16. For each contributing policy- and organizational-related factor for home referral barriers, please use the "5 Whys" method to determine the cause(s) of the above-selected contributing factors. If you wish to add any additional policy- and organizational-related factors, and the causes of those factors please add them here:

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* 17. Is your facility currently involved in an internal/organizational home dialysis referral initiative? If yes, please provide a brief description of the initiative in the comment box.

Yes

Comment Box

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* 18. Was this RCA tool easy to use?

Yes

If no, please tell us why or what about the tool you found difficult.

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* 19. How long did it take you and your team to complete the RCA?

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* 20. Please list that names, phone numbers, and email addresses of the two primary point of contacts for the New Shift: Home Dialysis Referral initiative. Please ensure that ALL facility personnel is updated in CROWNWeb.