Date of Award

Spring 5-6-2022

Document Type

DNP Project

Project Team Faculty Member

Dr. Melissa Bogle


Root cause analysis, home health record review, home health intake processes


Minimization of adverse events, reduction of inpatient admissions, and prevention of polypharmacy within home health are of importance due to the increasing number of Medicare beneficiaries. In 2019, CMS reported 5,266,931 patients were served by home health agencies, accounting for 7,439,849 episodes of care. It is projected that the number of beneficiaries will rise from 54 million to more than 80 million by the year 2030. Medical errors are now the third-leading cause of death in the United States, surpassing diabetes, Alzheimer’s, and stroke. The Agency for Healthcare Research and Quality identifies a lack of institutional intake processes as the leading cause for medical errors in home health agencies. An evidence-based 5-step root cause analysis was developed to address this concern in a private, Midwestern home health agency. Project objectives included: identifying root causes for the lack of uniform intake processes and access to patient records within the industry, assessing stakeholder knowledge of identified root causes, addressing provider obstacles for implementation and adaptation of new processes, and assessment of stakeholder readiness for change. Project methods included a comprehensive, niche specific PowerPoint presentation delivered to stakeholder leadership, a pre and post Qualtrics survey utilizing a 5-point Likert scale, and qualitative data review. The post-presentation survey resulted in a significant 75% increase in stakeholder knowledge and readiness for change. Outcomes of this project included self-reported feelings of empowerment and immediate follow-up action. Understanding the root causes of current barriers to patient care is recommended for all home health agencies. Newly acquired knowledge will support initiatives to streamline intake processes, decrease adverse patient events, and prepare this agency for a predicted influx of patients.

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