Root Cause Analysis The Process by jqu13899


									Root Cause Analysis:
The Process
Sue Ann Guildermann                      Betsy Jeppesen
Director of Education                    Vice President, Program Integrity
Empira                                   Stratis Health

Diane Rydrych                            Linda Shell
Assistant Director, Division of Health   Corporate Director, Education
Policy, Minnesota Department of Health   Volunteers of America
Why do you think this resident
falls down in about 35 minutes?

Clue #1:
What are we going to cover?

• Considerations for conducting a Root
  Cause Analysis (RCA)

• Steps in the RCA process
When RCA could be considered
•   Events with serious outcome for resident
•   Repeating incidents
•   Near misses/good catches
•   Examples:
    –   Falls
    –   Medication errors
    –   Pressure ulcers
    –   Plan of care not followed
When the information has been
Two approaches to RCA
 1) An RCA team uses information from individual
    interviews of the multidisciplinary staff involved in
    the event to uncover all possible causes and
    systems that led to the event.
 2) As soon as possible after the event, a group
    meeting that includes the multidisciplinary staff
    involved in the event is conducted to uncover all
    possible causes that led to the event.
Option #1 – staff interviews
and separate group RCA
• Staff collect initial information about the
• All staff who are on scene or have had
  contact in last 4 hours/shift are
• Within 1 week, information is brought to
  the multidisciplinary committee
Option #2 – RCA meeting with
staff involved in the event
• Information to be used in the meeting is
  – incident report
  – medical record account of the event
  – staff drawings/notes of the event
• Time line of the event is created
• Meeting is held within 48 to 72 hours
 – Determine who sets up the staff interviews and/or
   group meeting
 – Consider space needed for interviews or meetings
   and confidentiality of the conversations
 – Never compromise resident safety
Key players
• Staff from departments/units directly
  and indirectly involved in event
• Nursing administration
• Medical director, physician, provider
• Quality representative
• Administrator
• Facilitator/interviewer
• Pharmacy, therapy, social work, others identified
Coaching staff
• Initiated prior to setting up
  interview/meeting if staff member has
  not participated before
• Participation is a learning opportunity
• Participation is a chance for staff to tell
  their story
• Emphasis is on improving the system
Clue #2:
This 88 year old man has
atherosclerosis. He was
admitted from the hospital
10 days ago following an MI
when an angioplasty was
performed and a coronary
artery stent was inserted.

He has vision and hearing impairment.

His daily meds include: Lopressor, Coumadin, Zocor,
Lorazepam, a Multi-vitamin and a stool softener.

• Team training/group skills
  – Clinical background helpful, but not
  – Listening skills – uncover the story behind
    the event
  – Analytical skills – conversational/timeline
    versus investigation data gathering
Facilitator/Interviewer (continued)

• Strong boundaries
  – Bring people back to focus
  – Manage emotion (fear/anger) in the
    interview and at the table
  – Identify and draw out people
  – Engage entire team to give their perspective
    • Support everyone’s style

• Facilitator may be recorder as well
• In group meetings
  – The facilitator is listening for to the way
    staff members are speaking, which may
    lead to further exploration of a point for
  – The recorder can then capture what they
    are saying
Ground Rules
•   Confidentiality
•   Titles left at the door
•   All members must be active participants
•   No such thing as a bad question
•   Systems and process focus
    – No blaming or finger pointing
• Foster creativity
    – “You” have the solutions
Telling the Story
• Obtain the details of what happened
• What did you see, hear, etc?
• Encourage people to share
  – Identify opportunities and gaps as the story is
  – Why, Why, Why?
     • What was the resident’s position? Where was the
       equipment? Don’t stop here.
     • Why didn’t the process work as expected?
     • What was different this time?
Use of triage questions in the
RCA process
• Helps team understand event
• Assures a thorough investigation – “buckets”
  – Human factors                     – Training
     • Staffing                       – Rules, policies,
  – Communication/information           procedures
  – Equipment/environment             – Barriers
  – Uncontrollable external factors
Clue #3:
The resident was
found on the floor
next to his bed.

When asked, “What
were you trying to
do?” He answered,
“I couldn’t find my
glasses. So, I got
up to look for them.”
Continuing the RCA process

• Identify factors that may have led to the event
   – Identify system and process gaps
   – Identify opportunities for improvement
• Participant feedback on how to improve systems is
   – What could have been done differently?
• Develop an action plan
   –   Based on findings
   –   With target dates
   –   Responsible party
   –   Monitoring/measurement plan
• Follow-up
Spread the success/knowledge

• Share with staff and administration
  – Go beyond interdisciplinary care team
• Share learnings and collaborate with
  other facilities
Root Cause Analysis summary
• To be thorough, an RCA must include:
  – Determination of human and other factors
  – Identification of related processes and
    systems that contributed to the event
  – Analysis of underlying causes and effects –
    a series of whys?
Sue Ann Guildermann                    Betsy Jeppesen
Director of Education                  Vice President, Program Integrity
Empira                                 Stratis Health
952-259-4477                           952-853-8510 or 877-787-2847                         

Diane Rydrych                          Linda Shell
Assistant Director                     Corporate Director,
Division of Health Policy              Education and Learning
Minnesota Department of Health         Volunteers of America
651-201-3564                           651-503-8885    
Protecting, maintaining, and improving the health of all Minnesotans.

 Stratis Health is a nonprofit organization that leads collaboration and
  innovation in health care quality and safety, and serves as a trusted
   expert in facilitating improvement for people and communities.
Clue #4

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