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					INVESTIGATING WITH A DIFFERENT LENS:
RCA TRAINING FOLLOW-UP WEBINAR
September 1, 2010
STATEMENT OF WORK
Offer 8 adverse event investigation trainings based
 on the Patient Safety Improvement Corps team’s
 “Guide to Event Investigation in Nursing Homes”

Workshop Content:
 Event investigation based on PSIC training model’s
  QI concepts & methodologies
 Common QI language (RCA, 5-whys, PDSA,
  system-level thinking/solutions)
 Demonstrate how providers & state agency staff
  can use the tool
BEFORE THE TRAININGS BEGAN…

 Recruited Morgen Brodie, Patti Garibaldi & Demi
  Haffenreffer to co-present
 Contracted with OHCA for event planning – space,
  marketing, online registration
 Modified PSIC team’s guide from draft to final –
  now titled, “Guide to RCA in LTC”
 Shortened the “short form” – 3 pages to 1 page

 Developed the 4-hour presentation: multi-media,
  several small group activities, case studies
WHO ATTENDED?


 371   registered



 298   attended



 80.3%   attendance rate (free training)
PARTICIPATION BY LOCATION
April
 Eugene – 29 participants
 Wilsonville – 43 participants
 Medford – 31 participants
May
 The Dalles – 38 participants
 Bend – 24 participants
June
 Roseburg – 30 participants
 Wilsonville – 58 participants
 Portland – 45 participants
STATE AGENCY PARTICIPATION
   116 state agency staff attended / 298 total = 38.9%
                Ombudsman
                   (2)
                   2%

                    SPD Local
                      (25)
                      21%


                                  CCMU (61)
                  SPD Central       53%
                     (28)
                     24%
LTC PROVIDER PARTICIPATION
   182 LTC providers attended / 298 = 61.1%
              Home Health      Other (5)
                 (3)             3%
                 1%




                CBC (82)            NF (92)
                  45%                51%
THE FEEDBACK
   261 evaluations from 298 attendees in 8 trainings

   97.5% rated their ability to use the RCA Guide as
    able to very able (>/= to 3 on scale of 5) after
    attending the training

   96.5% strongly agreed or agreed that the workshop
    was effective

   66.9% of respondents said “yes, definitely” when
    asked if they will use the Guide to RCA in LTC in
    their work; 27.4% said “probably” and 5.5% said
    “not sure”
THE FEEDBACK
 Of the respondents who were unsure if they would
  use the guide the most commonly cited reason why
  was “time”
 43.7% of respondents said “yes, definitely” when
  asked if they believe the Guide to RCA in LTC will
  become the “profession’s standard;” 40.1% replied
  “probably;” 16.1% said “not sure” or “no”
 Of the respondents who were not sure or said no
  the most commonly cited reasons why were time,
  challenges of change & state wide commitment
  (providers & state agency)
THE MOST USEFUL ELEMENTS
 The 5-whys (a question asking methodology that helps
  you identify root cause)
 Action plans & goals with SMARTS (specific,
  measurable, attainable, realistic, timely & supported);
  track & trend incidents
 Looking at the whole picture - systems instead of
  people
 Recognizing that everyone has a voice; using a more
  team-oriented approach to investigating
 Gathering info, filling in the gaps & analysis
SUGGESTIONS FOR PRESENTATION CHANGES

             MORE TIME



           LONGER TRAINING



    MORE SCENARIOS / CASE STUDIES
COMMENTS FROM STATE AGENCY STAFF
“Enjoyed being mixed with LTC staff!” SPD
  Supervisor

“Very important & useful tool because as a surveyor I
  often find the people writing the investigation may
  not have training or a guide to use.” CCMU
  Surveyor

“Broadening my perspective, analyzing systems & the
  list of contributing factors [elements of class most
  useful to you]” APS Investigator

“Great training! I will use this as a tool in passing info
  to facility.” CCMU Surveyor
COMMENTS FROM LTC PROVIDERS
“I am the point person for incidents & feel better
   prepared to gather info from different perspectives.”
   CBC DNS

“Asking more whys – gathering more data [elements of
  class most useful to you]. Good presentation;
  hopefully the beginning of great things!” NF Charge
  Nurse

“Very informative, learned a lot, made me stop & think.”
  CBC Activity Director

“Using 5-whys, applying findings of RCA to other
  residents/situations [elements of class most useful to
  you].” NF Administrator
SURVEY MONKEY RESULTS
 Distributed July 14; survey closed July 30
 117 respondents; 64/117 state agency staff
  (54.7%), 43/117 long term care providers (36.8%),
  10/117 “other” (8.5%)
 78.5% agreed that the training has made a positive
  difference in how they do their job
 88.7% agreed that their organization is supportive
  of using RCA tools.
 79.3% agreed that the Guide to RCA will become
  the profession’s standard
RCA IMPLEMENTATION:
GATHERING INITIAL DATA (N=111)
RCA IMPLEMENTATION:
DOING THE ANALYSIS (N=111)
RCA IMPLEMENTATION:
ID’ING CONTRIBUTING FACTORS (N=111)
RCA IMPLEMENTATION:
USING THE 5 WHYS (N=111)
RCA IMPLEMENTATION:
INITIATING PDSA (N=111)
RCA IMPLEMENTATION:
INITIATING SYSTEM THINKING (N=111)
RCA IMPLEMENTATION:
DEVELOPING AN ACTION PLAN (N=111)
RCA IMPLEMENTATION:
SETTING GOALS WITH SMARTS (N=111)
RCA IMPLEMENTATION:
CONDUCTING A RCA (N=111)
“REAL LIFE” EXAMPLES OF IMPLEMENTATION

“Discussed with a LTC provider how RCA of a
  fall incident with injury may have led to the
  facility not needing to report the incident to
 SPD (as possible neglect of care) & resulted
   in a more appropriate preventive plan for
                   the resident.”

           State Agency staff member
MORE ON THE “REAL LIFE” EXAMPLE
   NF self-reported resident fall resulting in pelvic fx
    with the following info:
       Staff not present when resident fell
       Resident slipped on large amount of water in room,
        flowing from bathroom sink
       Resident in need of assistance to transfer & ambulate,
        per MDS assessment
       Resident at risk for falls & encouraged to summon
        assistance when transferring or ambulating, per care
        plan
       No eval about why resident was ambulating
        independently
       Did not identify that abuse/neglect had been ruled out
MORE ON THE “REAL LIFE” EXAMPLE
   CCMU complaint investigation initiated based on
    self report which found:
     Resident’s care plan did not reflect improvement in
      transfer/ambulation ability & level of staff assistance
      needed (DC to CBC imminent)
     Resident’s diagnoses included diabetes & neuropathy
     Interview with resident indicated that shutting off the
      sink was difficult because, “my hands don’t work like
      they used to”; paper towels used to improve grip on
      faucet. Resident didn’t share this with facility, “they
      never asked.”
     Interview with LN indicated that Maintenance informed
      of slow draining sink, “out of order” sign placed above
      sink
MORE ON THE “REAL LIFE” EXAMPLE
   A root cause analysis would have:
     Enabled the facility to rule out abuse, making this event
      a non-reportable incident
     Identified a system issue regarding care plan updates –
      if the care plan had been updated the resident’s
      ambulatory status & need for staff assistance wouldn’t
      have been in question & may have eliminated the need
      for an onsite complaint investigation; RCA may have
      identified why the care plan was not updated (for this
      resident & potentially others)
     Identified that the resident’s diagnoses were a factor in
      an overflowing sink instead of the assumption that it
      was slow draining (using 5-whys)
TESTIMONIALS FROM PROVIDERS



“RCA tool identified a step that was being left out of
                 one of our systems.”
                    NF Provider

“Had a significant event fracture recently & used it for
                       reporting.”
                     NF Provider
CHALLENGES MENTIONED IN SURVEY
   8/32 respondents cited time
     Length of the process
     Takes more time in the beginning
     Too busy
     “Although it took awhile to get into the routine, now that
      we are doing it every week, there aren’t as many to
      review.”
   4/32 respondents cited lack of staff
     Getting total involvement & understanding from staff
     Difficult to get staff on board
     Challenging to train staff across the board
Q&A
   Questions regarding implementation?

   Any successes to share?

   What challenges are you coming up against?

   Ideas for implementation?

   Other?
RCA TOOLS, RESOURCES ON WEBSITE

              www.oregon.gov/OPSC

 RCA training powerpoint (without videos)
 Guide to RCA in Long Term Care

 Condensed version of Guide

 Appendix to Guide

 Definitions
FOR MORE INFORMATION
                   Amy Carl
       Oregon Patient Safety Commission
       amy.carl@oregonpatientsafety.org

                Patti Garibaldi
    Nurse Consultant, Consonus Healthcare
       pgaribaldi@consonushealth.com

              Demi Haffenfreffer
   Nurse Consultant, Haffenreffer & Associates
            demi@consultdemi.net

				
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