All posts by ThinkReliability Staff

ThinkReliability are specialists in applying root cause analysis to solve all types of problems. We investigate errors, defects, failures, losses, outages and incidents in a wide variety of industries. Our Cause Mapping analysis method of root causes, captures the complete investigation with the best solutions all in an easy to understand format. ThinkReliability provides investigation services and root cause analysis training to clients around the world and is considered the trusted authority on the subject.
Root Cause

Health Declines as Veterans Wait for VA Care

By ThinkReliability Staff

On September 5, 2014, a tragic story was released of a man who lost most of his nose due to spreading cancer.   When diagnosing cancer, it’s generally acknowledged that the earlier the cancer is caught, the less the risk of the cancer spreading.  In this case, the veteran waited over two years for a biopsy.  He is one of thousands of patients who have had to wait unreasonable amounts of time for care through the Veterans Administration (VA) system.

Although the issues with delay of veterans care appear to be nationwide, looking at one particular incident can help shed some light on not only what went wrong, but possibilities for reducing the risk of it happening in the future.  The Inspector General examined dozens of cases of patients who died while waiting for care at the Phoenix VA hospital in order to determine the impacts of the delayed care, the causes related to it, and recommendations for fixing the problem.  We can also examine the impact, causes and potential solutions for the care issue by performing a root cause analysis based on the story of this particular patient.  (His case was not covered in the IG report, which primarily examined deaths of veterans while waiting to be seen at VA facilities.)

We can capture the analysis in a Cause Map, which visually lays out the cause-and-effect relationships that resulted in an incident in order to provide the maximum opportunities for improvement.  After the what, when and where of the incident are captured, it’s important to determine the impacts to the goals resulting from a particular issue.  In this case, the patient’s safety was endangered because of the spread of cancer.  The patient services goal was impacted because the patient lost most of his nose as a result of inadequate treatment at the healthcare facility.  The schedule/operations goal is impacted due to the delay in treatment of the patient.  In order to better quantify the effects of an overarching issue such as this one, a frequency of events is essential.  In this case, the Inspector General found that delayed treatment was clinically significant for at least 28 other veterans at the same VA hospital.  (The Inspector General also found that 40 veterans died while waiting for appointments but was unable to determine if the deaths were due to the delays.)

Beginning with an impacted goal, asking “Why” questions adds detail to the Cause Map.  The spread of the patient’s cancer was caused by a delay of treatment.  Treatment was delayed due to the exceptionally long wait for a biopsy (two and a half years) as well as the wait between the diagnosis and treatment (surgical removal).  Insufficient capacity and large numbers of veterans seeking care at the VA hospital resulted in veterans waiting months or even years for care.  Because (as described by a whistleblower physician from the site) the site used “secret” waiting lists (where patients were effectively put on a non-official waiting list for the waiting list so that the reported wait was within an acceptable time frame), oversight of the facility was minimal.  As in this case, many veterans prefer to get care at a VA facility and/or don’t have another type of insurance that would cover the costs incurred for healthcare needs.

As expected, the results of these investigations have resulted in a number of personnel being removed from their positions in the VA.  The “secret” waiting lists were used to hide the fact that the VA hospitals don’t appear to have the capacity for the number of veterans that need treatment.  Significant additional funding is being directed towards the VA in order to build more hospitals and hire additional medical staff.   In the meantime (and possibly continuing into the future if capacity continues to be inadequate), arrangements for veterans to receive covered care at other facilities are being made.

In light of these highly publicized issues, hopefully the VA will receive the funding and oversight it needs so that the nation’s veterans can receive the care they deserve.

Root Cause

Concern about Quality of Medical Care for Inmates

By ThinkReliability Staff

Those in the custody of law enforcement are almost completely dependent upon law enforcement for their basic needs.  One of these needs that is not always being met involves proper medical care, or even checks after the declaration of a medical emergency.   Per Dr. Ronald Shansky, a physician who performs court-ordered monitoring of inmate conditions for Milwaukee County, Wisconsin, failure to provide proper medical care is a failure to uphold constitutional obligations to those in custody.  After all, he says, “The inmate is completely dependent.  Unless the system creates the opportunity for the medical tests to be done, the medications to be provided, it’s not going to happen.”

In Milwaukee County, which was the subject of a recent investigative report by the Milwaukee Journal Sentinel, 18 people died in the custody of law enforcement in the county between 2008 and 2012.  Of these deaths, 10 were found to be related to improperly treated or monitored conditions.  By performing a detailed investigation of just one of these deaths, solutions that could reduce the risk of all custodial deaths due to improperly treated or monitored conditions can be incorporated.

We can perform this investigation by creating a Cause Map, or visual root cause analysis.  We begin with the specifics of one of the 10 cases of custodial death.  For this example, we’ll look at the death of Jeremy Cunningham.  Mr. Cunningham died the morning of June 22, 2011, while he was being held at the Milwaukee Secure Detention Facility for violation of parole.  Two important factors to note were that the inmate reported that he had alcohol and drugs in his system (taken within 8 hours) and that the inmate had a heart condition.

Next we determine the impact to the goals from the perspective of the Department of Corrections.  The inmate safety is impacted due to the death of a person in custody. Because of the constitutional obligation of law enforcement to care for those within their custody, the compliance goal is impacted.  Additionally, due to the insufficient treatment of the victim while in custody, the inmate services goal was impacted.

Beginning with the inmate safety goal, we can ask why questions to determine the causes of the impact to the goal.  The patient died because of a health issue that was not sufficiently treated.  Though the autopsy determined that the inmate died from cocaine poisoning, a pathologist who reviewed the results believes that alcohol withdrawal is more likely.  Because the cause of death is still under debate, we can use a “?” to indicate that it is not yet known (and more evidence is needed to determine the actual cause of death, though this is unlikely to occur).

Had the patient experienced the health issue but received treatment, he would have been less likely to die as a result.  Thus, the insufficient treatment from the prison staff is a cause of his death.  From available information, several opportunities were missed to assess the inmate’s health needs.  In other cases involving inmate deaths, an expectation of 30-minute check of prisoners is discussed, though it appears that requirement is not frequently being met.  This is likely because of chronic understaffing due to funding issues.  Even after the inmate’s roommate pressed the emergency call button when the inmate begin seizuring, nobody was sent to check on the condition of the inmate. (The emergency call button was pressed during the night, and the inmate was found dead in the morning.)  At the time of the death, there was no policy in place specifying what to do upon receipt of an emergency call, though the alcohol withdrawal instructions state that an ambulance should be called if an inmate experiences seizures.

Although the inmate had reported use of alcohol and cocaine within 8 hours before his incarceration, he was not monitored for withdrawal symptoms, although nurses had indicated monitoring was necessary.  Additionally, the prisoner did not receive any special care or instructions due to his heart condition.  It’s possible his heart condition wasn’t known – he died within 20 hours of entering the facility, which does not have an on-site medical practitioner, and prison medical records are delivered within 24-48 hours.

The failure of the system to provide adequate care to this inmate, as well as the 9 others who died in custody due to failure of monitoring or treatment has led to some changes being adopted by the Department of Corrections.  (Other changes are being forced by the legal system.)  These include posting notices on the doors of inmates who need extra attention, analyzing blood alcohol content upon arrival, and requiring an in-person evaluation to   respond to all emergency calls from within the prison. Hopefully these changes will reduce the failures that led to Mr. Cunningham’s death as well as some of the other deaths.

To view the investigation of Mr. Cunningham’s death, as well as a timeline outlining all 18 deaths in Milwaukee County law enforcement custody, please click “Download PDF” above.  Or click here to read more.

Root Cause

27 Patients to be Tested After Ultrasound Probe Sterilization Error

By ThinkReliability Staff

On December 21, 2013, 27 men were notified that, due to improper sterilization of equipment used for their prostate procedures, they should be tested for HIV and hepatitis B and C.   Both the medical center and patients involved are understandably concerned about how they got to this point.

In order to better understand the issues involved, we can put together an investigation file using Cause Mapping, a visual form of root cause analysis.  First, we capture the basic information about the issue.

The procedures were performed from September 19 to December 10 of this year at a Seattle medical center and involved ultrasound probes used for prostate procedures.  Because more than one date is involved, we can use a timeline to add more detail to the investigation.  In this case, patients were found to have been affected beginning September 19 and ending December 10, though it’s not clear if the incorrect sterilization began on that date, or if that was the first date that a probe was used on a patient with a communicable disease.  The improper sterilization was reported to hospital officials December 17 and affected patients were notified beginning December 21st.  As a result of information released by the medical center, we know that one step in the sterilization process for the probes was not completed.  We capture this as an important “difference” that may aid in the analysis.

Next, we determine the goals that were impacted as a result of the issue.

The patient safety and patient services goals were impacted due to the risk of disease transmission for the 27 patients (the probability of which is estimated to be very low).  The compliance goal is impacted because of equipment that was not sterilized as required.  The labor goal is impacted because the medical center is paying for two rounds of HIV and hepatitis testing for the affected patients.  If it is determined over the course of the investigation that other goals were impacted as well, these can be captured in the Problem Outline as well.

Once we have determined the impacted goals, we use these goals as the first “effect” to determine the cause-and-effect relationships that resulted in the issue.  In this case, the patient safety and services goals were impacted due to the risk of disease.  The disease risk resulted from the reuse of prostate probes that had the possibility to spread disease.  The disease risk occurred because the probes may have been used on a patient that had a communicable disease and the probes were not properly sterilized before their reuse.

We can show the steps that should have occurred in the sterilization process of these probes, as well as where the specific issue in the process occurred, in a Process Map.  This map shows the steps involved in a procedure, in this case the ultrasound probe sterilization procedure.  After a probe is used, it goes through a three-step process, involving cleaning, disinfecting or decontaminating with a disinfectant spray, then sterilization by being doused with sterilization fluid.  Then the sterilized equipment is placed in a protective sheath before re-use.  (Because of the use of this protective sheath, the probe, when properly used, does not contact the patient, decreasing the risk of disease transmission.)  In this case, the sterilization step was not performed.

We include the fact that the procedure was not performed properly in the Cause Map.  The Chief Medical Officer reports that their investigation found that the cause was “human error” and no more information has been released.

In order to determine effective solutions to prevent the issue from recurring, more detail needs to be obtained about the expectations for the process being performed, as well as the verification (if any) that took place to ensure that the procedure was being performed correctly.  Once it’s possible to determine what allowed the process to break down, safeguards that will reduce the risk of it happening again can be implemented.

To view the initial investigation file, including the Outline, Cause Map, Timeline and Process Map, please click “Download PDF” above.

Root Cause

Patient Gets MRI (and a Diagnosis) Only After 24 Visits to 13 Doctors

By ThinkReliability Staff

In a tragic case of incorrect diagnosis, a 16-year-old patient died January 24, 2013, eleven months after being diagnosed with “migraines”.  In fact, the patient had a rare brain tumor (known as a disseminated oligodendroglioma-like leptomeningeal tumor).  She died eight days after receiving an MRI that finally properly diagnosed the causes of her headaches, numbness, nausea and eyesight problems.

It’s unclear if earlier diagnosis would have saved the life of the patient.  Though the prognosis is poor for a leptomeningeal tumor, a oligodendroglioma that is treated before it is disseminated gives a long-term survival chance to 80-100%.  The tumor had disseminated once it was found on the MRI, eleven months after the patient was diagnosed with migraines.  However, even if her prognosis was poor, the patient could have spent the last eleven months of her short life enjoying time with her family and friends, instead of making 24 trips to 13 different doctors and, in one particularly devastating appointment, being accused of “putting the symptoms on”.

Although the coroner at the inquest said there was no need to make a formal recommendation for changes at the hospital that failed to diagnose the patient, a spokesperson for that hospital said “In the next few weeks, many of the clinicians who looked after Natasha will be meeting to discuss this sad case and ensure that any opportunities for learning are not missed.”

It is hoped that these opportunities for learning can reduce the possibility of another patient suffering as this patient did, due to a misdiagnosis.  Misdiagnosis is a common source of medical error.  According to an article by Michael Astion, MD, PhD, “Available data suggests that misdiagnoses occur in 15% or more of clinical cases, but overall there is very limited data on the frequency of misdiagnosis in medicine.”  Especially in rare clinical cases such as this one, sharing details of the disease and diagnosis may help other clinicians in the same position.

In order to effectively determine lessons learned and improvements that can be made, the details of a case need to be presented clearly and concisely.  I’ve put together the details of the case in a Cause Map, which uses cause-and-effect to demonstrate the linkage of the issues that led to the tragedy discussed here.

In a blog discussing the cases and possible responses, Suzanne Leigh suggests that if an MRI was denied, other cheaper alternatives, such as a CT scan, be considered.  She also suggests a much more thorough review to “ensure that in the future, scans are  not withheld from patients with potentially life-threatening conditions”  and that the hospital involved should “study the flaws in the system and human errors that led to the failure of 13 doctors to order a diagnostic MRI that would have resulted in emergency treatment earlier in the disease’s progression”.  Given the tragedy of this case, the suggestions seem far more appropriate than the treatment of the patient over the last year of her life.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause

Baby Suffers Brain Damage After Delay in Newborn Testing Results

By ThinkReliability Staff

A recent watchdog report by the Milwaukee Journal Sentinel found that 3.9% of screenings from a particular hospital took 5 days or longer to reach the lab, though the state guidelines are 24 hours.  (Statewide, 2.9% of samples take five days or more.)   This typically occurs because of a practice called “batching”, where multiple samples are saved to send in as a group.  Although the practice of batching is not recommended, and the state guidelines warn “DO NOT BATCH SPECIMENS”, there are no laws requiring hospitals to send in samples within the 24 hours, nor are there are penalties for not doing so.  According to the state’s newborn screening advising committee, some hospitals continue to batch samples, even though it is the state – not the individual hospitals – that pay to have the blood samples sent to the lab.

A case turned tragic illustrates the problem with waiting to send these blood samples.  We can capture the cause-and-effect relationships that led to a baby suffering brain damage within a Cause Map, or visual root cause analysis, which allows a detailed examination of the issues that led to the nearly fatal outcome.

On October 2, 2012, a baby was born at a Wisconsin hospital.  Per guidelines, a blood sample was taken for newborn screening when the baby was 32 hours old.  However, that blood sample (likely due to batching, though the hospital has not officially confirmed this), was not sent to the state lab until October 8.  The state lab tested the sample October 9 and determined that the baby had Argininosuccinic aciduria, which occurs in only 1 of 70,000 babies in the US. Though it can be fatal, if it’s caught early, the treatment involves some extra care with feeding and an extra day or two in the hospital.

In this case, because the sample was delayed, a diagnosis wasn’t made before the baby had lapsed into a coma.  He was transferred first to a larger hospital, then to one of two hospitals in the state that can perform newborn dialysis – necessary due to his off-the-charts ammonia levels.  A quick-thinking doctor utilized a novel technique of cooling that baby, which saved his life.  The cost of all this treatment was nearly $500,000 and the baby has suffered brain damage, though the extent is not known.

The Journal Sentinel has published data showing how long samples took at Wisconsin hospitals in an attempt to raise public consciousness of this issue.  The state, as well as other experts, continues to advise hospitals of the importance of sending blood samples to the lab for screening within the recommended 24 hours.  It could save a life.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause

Students Will Receive a Meningitis Vaccine Not Yet Approved in the US

By ThinkReliability Staff

In an unusual move, on November 16, 2013 the US Food and Drug Administration (FDA) approved the importation and use of a vaccine not yet approved in the US to attempt to minimize the spread of a rarer – and more difficult to prevent – strain of meningitis on a college campus.

Information about the outbreak, including the effects, causes, and recommended solutions, can be captured in a Cause Map, or visual form of root cause analysis.  This method of problem-solving begins by capturing the background information on the event, then determining the impact of the event on the organization’s goals.

The outbreak began at Princeton University in March of this year.  Meningitis outbreaks can be more common at college campuses because of the close living quarters.  The specific strain involved is known as serogroup, or type B, which has been more difficult to create a vaccine against because the coating on the bacteria is different than that from other types, for which a vaccine was developed in 2005.  Since that vaccine, the number of cases of meningitis on college campuses has declined, though there were 160 cases of B strain meningitis in the US last year.  (In the US, B strain is rarer than other types.)  This is the first outbreak of B strain meningitis in the world since the vaccine was approved.

This outbreak has impacted the safety goal, as the potential for serious injuries and fatalities is high.  The spread of meningitis can be considered an impact to the environmental goal, and the customer service goal is impacted by students being sickened by meningitis.  Treatment and vaccination are an impact to the labor/time goal.

Beginning with the impacted goals and asking “why” questions develops the cause-and-effect relationships related to the incident.  In this case, the outbreak resulted from the spread of meningitis due to coughing or contact among the close quarters common on a college campus, and the fact that students were not vaccinated against this particular strain of meningitis.  A vaccine for the B strain of meningitis has not yet been approved in the US as it was recently developed, although it was approved for use in Europe and Australia earlier this year.  Developing a vaccine for the B strain was difficult (it took over 20 years) because of the differences in bacteria coating from other strains.

Though the vaccine has not been approved for general use in the US, the FDA and Princeton University officials determined that the prevention benefits outweigh the risk of its use.  Specifically, students at Princeton will be offered two doses of the vaccine, paid for by the university.  The vaccines are not mandatory.  In addition, students are being reminded to wash their hands, cover their mouths while coughing, and not to share personal items.  It’s also hoped that holiday travels will end the outbreak as students disperse, though it’s also possible that the travel could spread the disease, though this is considered highly unlikely by health officials.   Time will tell if these actions are adequate to stop the spread on campus.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause

After Hurricane Sandy, Medical Centers Work to Prevent Future Issues

By ThinkReliability Staff

As a result of both infrastructure damage and power failures due to Hurricane Sandy, five major hospitals in the New York City area had to be evacuated (see our previous blog about one hospital’s evacuation).  Medical centers in the impacted areas are still recovering, while trying to determine what should be done to prevent future risk – and who should be responsible.

Historically, it’s been difficult to tell whether or not a hospital’s emergency plan is adequate until it’s tested.   In May of 2011 (less than 6 months before Sandy hit), the U.S. Department of Health and Human Services announced that a majority (over 76%) of hospitals that were part of the National Hospital Preparedness Program “met 90% or more of all program measures for all-hazards preparedness in 2009”.  Many of the hospitals that were evacuated had earned accreditation by the Joint Commission – which includes criteria for emergency preparedness and backup power capacity.   In fact, according to the Joint Commission, the hospitals that were forced to evacuate would still be accredited based on the existing codes.  Says George Mills, the director of the Joint Commission’s Department of Engineering, “Yes, we would accredit them. We have no standards that say get your generator out of the basement.”

But that is exactly what many hospitals that have been affected by storm surges are doing.   NYU Langone Medical Center has upgraded its infrastructure and purchased flood barriers which can be deployed in the case of flooding. The hospital was reimbursed $150 million for rebuilding costs by the federal government shortly after the storm.  Bellevue Hospital Center, where the basement flooded in 45 minutes and took 5 days to pump out, also installed flood barriers and will be raising its backup generator’s fuel pumps from the basement.  Coney Island Hospital has elevated its outside electrical equipment and installed temporary barriers, but is looking at the elevation of its emergency department, which is on the first floor.  (In addition, the Manhattan Veterans Affairs Medical Center evacuated before the storm and experienced complete flooding of the basement and ground floor, resulting in power failures.  Also evacuated were 200 patients from the Henry I. Carter Specialty Hospital and Nursing Facility.)

The city’s Health and Hospitals Corporation President Alan Aviles says the cost of repairs, response and long-term protection from floods will be more than $800 million.  The projects will not be started until the city ensures that the Federal Emergency Management Agency (FEMA) will cover the costs.

According to Al Berman, the head of disaster recovery organization DRI International, the city won’t know how effective these measures have been unless much more rigorous testing is done . . . or until the next storm hits.  In his words, “A disaster is a terrible time to test your plan.”

The information related to the impacted goals as a result of the evacuations from Hurricane Sandy are captured in an Outline, the causal relationships leading to the evacuations and the proposed solutions are captured in a Cause Map, which can be viewed by clicking “Download PDF” above.  The Cause Map allows us to visually capture the cause-and-effect relationships in a logical, organized manner that clearly demonstrates the impact of various causes and the benefit of proposed solutions.

What about the hospitals that managed to weather the storm?  The Shorefront Center for Rehabilitation and Nursing Care in Brooklyn, just a few yards from the Atlantic Ocean, was praised for its handling of the storm – and assistance it provided to other healthcare facilities.  Says their administrator, Loyola Princivil-Barnett, “Our executive team have been taking, and are taking, emergencies very seriously.  It’s a matter of life and death.”

Root Cause

Analysis of Causes of Patient Data Breaches

By ThinkReliability Staff

When dealing with a seemingly overwhelming problem, care should be taken to ensure that resources are used most effectively by addressing the causes that have the biggest impact on the issue.  Take the case of HIPAA breaches of medical records.  Since February of 2010, 26.8 million individuals in the United States have been impacted by a data breach.  There are multiple potential causes that could result in these data breaches. So, where should efforts be directed to be most effective?

Looking at actual events and determining the probability of different types of failure can better direct your solutions, even if your organization hasn’t personally experienced a data breach.  We do this in a proactive Cause Map, which looks at potential causes and – when data is available – determines the relative probability of each contributing cause.  Luckily for us, this analysis has already been performed for data breaches reported to the HHS since February 2010.  We will use here breach analysis and graphs created by medical software research resource Software Advice in a recent report on the subject.

The biggest cause of patient data record breaches is theft.  Theft accounts for at least 48% of breaches.  (There were also incidents described as combination, other or unknown, which may also involve theft.)   As an example, a health insurance provider lost nine server drives that included information for 1.9 million people, two years after a portable disk drive was stolen that included personal data for 1.5 million members.  (View our analysis of patient data breaches caused by theft in our previous blog.)

The next largest cause of patient data breaches is unauthorized access.  Unauthorized access is the cause of 18% of data breaches.  These types of breaches have the potential to result in employee action in addition to the other goals that are impacted.  These events may involve outside contractors, or “Business Associates” (BAs).  BAs are involved in 22% of incidents, but account for 48% of impacted individuals due to data loss.  An example of a patient data breach caused by an outside contractor is the case involving records of 20,000 patients, which were posted online by a contractor.  (View our analysis of this data breach in our previous blog.)

Loss accounts for 11% of patient data breaches.  This includes the largest patient data breach from the time period covered, when a TRICARE BA (contractor) lost backup tapes, impacting the records of nearly 5 million patients.   Improper disposal, such as when a shredding company abandoned the records of 277,000 patients in a public park, accounts for 5%.  Hacking also occurred in 6% of breaches, such as when the servers at the Utah Department of Health were broke into and records for almost 800,000 people were stolen. (Remaining events are classified as a combination of the above, other, or unknown.)

The HIPAA Omnibus Rule clarified liability for Business Associates and subcontractors, which should serve to reduce their involvement in data breaches.  But for the events that don’t involve outside parties, how can these events be reduced?

Focusing on two of the most likely causes of breach – theft and loss – encryption can reduce the risk that data can be accessed if physical devices are stolen.  Laptops account for 22% of breaches, and other portable devices account for 12%.  However, encryption won’t help with paper records, which account for 23% of data breaches.  In these cases, limit to access of records and prevention by removing records from the storage site can help, as can moving from paper records to electronic health records, which accounted for only 2% of  data breaches.  However, the storage devices used for electronic health records, including laptops, as discussed above, network servers (10%), computer (13%) are more likely to be involved. Because physical storage devices account for so many data breaches, whether or not electronic records are being used, cloud storage is worth consideration.  Although hacking is still a concern, remember that it accounts for just 6% of breaches – as opposed to theft and loss, which make up nearly 60% of breaches.

To view the proactive analysis/ Cause Map of these data breaches, please click “Download PDF” above.  Or click here to read more.

Root Cause

Glitches with Federal Health Care Exchange Website Cause Concern

By ThinkReliability Staff

The website to allow individuals to sign up for the federal Health Care Exchange created as part of the Affordable Care Act opened at midnight on October 1, 2013.  Delays and glitches with the site itself caused difficulties for many trying to enroll.  Three million visitors are said to have visited the site between midnight and 4 p.m. on opening day, though the numbers of how many were actually able to enroll will not be released until November.

This creates a problem not only from a customer service perspective (though that is certainly an important impact to the federal government’s goals of trying to create a consumer-friendly website), but also with regard to the mission of providing affordable healthcare to the population and the labor and time required by federal workers for its success.  Because the cost for healthcare is more for older, sicker parts of the population, more younger, healthier people will need to sign up for the exchanges to keep the insurance affordable.  Some people who go to the website are now being directed to apply by phone, or mail, but because the site incorporates automatic verification of personal information, that will need to be done manually by employees when people apply in other ways, this increases the cost of the program.

Though specific details on some of the issues facing the exchange have not yet been released, there are some known issues that have been discussed in the media.  One of these is the available capacity for the site.  The site was planned for a maximum of 50,000 simultaneous users.  During the first day of the exchange, the site saw up to five times that many simultaneous users.  The numbers are presented as being based off the 30,000-maximum simultaneous users to the Medicaid site, but how the actual number was determined is unknown.  An increased burden on the site due to the 36 states that decided not to create their own state-run exchange contributed to the high number of users.  It was thought that the promise of federal money to support the state-run exchanges would encourage more states to participate.

The requirements for the website have been described as “unprecedented” – not only was the website designed to handle a high number of simultaneous users, it also has to share information from multiple data sources, including the Internal Revenue Service, Social Security Administration, and Homeland Security to verify information and determine access to plans and tax credits.  Based on the number of glitches and delays seen in the first weeks of the exchange website, the testing of the launch appears to have been inadequate.  Factors that may have played a part are lack of funding due to lack of support for the Affordable Care Act by Congress, and a delay in creating the infrastructure of the system over a concern that the Act would be overruled by the Supreme Court or Congress.

Information technology experts say that lessons learned from other sites – such as state-run exchanges that have already been successfully operated, or even the Medicaid site – were not applied effectively to the exchange.  The organization tasked with oversight of the exchange – Centers for Medicare and Medicaid Services (CMS) – has little experience with managing a website of this magnitude.  It has also been suggested that the contractors hired to support the site may be less able to react because government contracting can be preferential towards older, more entrenched companies.

As more information is released, the analysis of an issue becomes more detailed and allows for more effective, deliberate solutions.  The information that is currently publicly available was used to create an initial, high level Outline and Cause Map.   (To view the Outline and Cause Map, please click “Download PDF” above. )

As an immediate, but temporary solution, an online waiting room was created in hopes that it would allow an increased number of users to be on the site at the same time.  Additionally, the ability to browse anonymously – without creating a profile – was incorporated, in hopes that this would decrease traffic to parts of the site that require personal information verification for those who are just looking at the site.

A team of experts has been tapped to fix the glitches with the site.  It’s not clear who will ultimately be responsible for the fixes, though many have recommended the creation of a new position to oversee the entire exchange.  If issues with the site continue to cause delays, the sign-up period may be extended as a back-up solution.  The administration will be watching the fixes to the site carefully and determining what more is needed.  However, they’ve got to hurry – the enrollment period ends December 15 for coverage by January 1, 2014.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause

National Effort Improves Cardiac Arrest Survival Rates

By ThinkReliability Staff

October is Sudden Cardiac Arrest (SCA) Awareness Month.  In Northern America, more than 300,000 people are affected every year by out-of-hospital SCA, which occurs when the heart no longer beats properly.  According to the American Heart Association, about 92% of SCA victims die before reaching the hospital.

Survivability of SCA is dependent on the length of time between SCA and chest compressions that allow blood flow to the heart and brain.  This can be accomplished by non-medical personnel using Cardiopulmonary Resuscitation (CPR), known as “bystander CPR”, which can provide lifesaving treatment for a victim of SCA until medical personnel arrive.

In Denmark, the rate of patients who received bystander CPR in 2001 was 21.1%.  The country embarked on a national initiative to improve SCA survivability.  This initiative included increased training of residents as early as elementary school.  Instructional kits were provided, and learning CPR was required in order to receive a driver’s license.  The percent of patients who received bystander CPR increased from 2001 to 2010 to 44.9%.

In addition to the increased education of the general population about CPR, changes were made to improve care provided after SCA by hospitals and emergency medical services.  According to a study in the Journal of the American Medical Association, these changes together have improved the survivability of all stages after SCA.  From 2001 to 2010 in Denmark, cardiac arrest patients arriving at a hospital alive increased from 7.9% to 21.8%.  In addition, 30-day and 1-year survival also increased, from 3.5% to 10.8% and 2.9% to 10.2%, respectively.

Denmark’s initiative hopes to lessen the reluctance bystanders may have to perform CPR due to lack of training.  In addition, the American Heart Association recommended in 2008 that laypersons perform compression-only CPR (no breaths) if they are unable or unwilling to provide rescue breaths.  This may have also decreased the reluctance of bystanders to perform CPR due to concerns about spread of disease, or feeling uncomfortable giving rescue breaths.

Providing additional training to emergency medicine providers can also improve survivability.  Another recent study by the University of Arizona has found that improving the quality and effectiveness of CPR performed by emergency medicine providers improved survival rates.  In the study, rescuers were provided real-time feedback as to the quality of the CPR being provided, as well as training that emphasized a team approach.  Before these interventions, 26% of SCA victims survived to hospital discharge.  After the interventions, 56% of victims survived to discharge.

Although CPR dates back to 1740, improvements in availability and quality are still being found that can increase survivability of SCA victims.  Because of the importance in quick and effective action, the importance of action by non-medically-trained bystanders to the survival rate after SCA provides strong support for layperson CPR training.

To view the Outline and Cause Map including the cause-and-effect of the improvements to survival rate in Denmark as a result of interventions and improvements, please click “Download PDF” above.