Post on 15-Dec-2015
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Harness the Power of Root Cause Analysis
June 19, 20122:30-3:45
Joyce Rutherford Donner
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Teaching Root Cause
• Critical Thinking Skills
• Natural Talent
• Long, Hard Slog
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Important First Step
Investigation Phase:Investigation Phase:
Researching, Asking QuestionsResearching, Asking QuestionsRe-enactmentRe-enactment
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Results of a Good Investigation Include Thoughts About:
• Systems breakdown• Training needs• Resident needs• Environmental needs
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What is the Root Cause?
• Root Cause - a specific underlying reason› Can be reasonably identified› Management has control to fix, change, or care plan› Facilitates development of actions for prevention
• The process of choosing a Root Cause › Will identify “Causal Factors,” contributors that, if
eliminated, would have prevented and/or reduced the severity the occurrence.
› Is not a 1-person job.
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Ishikawa (Fishbone) Diagram
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Cause and Effect Diagram www.skymark.com/resources/tools/cause.asp
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Fall from W/C
Trying to get into bed by himself
Staff didn’t find out if he wanted to go to bed
Aphasic and doesn’t have communication board
Res. can’t communi-cate
Confusion d/t low O2 sat
No oxygen therapy
Physician has not ordered
Alarm did not sound
Battery dead
No maintenance program
No data re: O2 sats
No SLP orders
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Asking “WHY” Without Completing The Investigation Can Lead To Dead Ends
• Resident fell› Why
• Because she tried to stand up without assistance› Why
• I don’t know › Why don’t you know?› I didn’t ask her or the staff
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Practice
• Using one report so all are working on the same problem› Groups of 3-4› Flip chart paper and markers OR post-it notes› Space to meet as a group
• Create a cause and effect diagram
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Trainer’s Role During Practice Session
• Assist with the “why” process to prevent jumping to conclusions› Logical conclusion and not what the first
impression was› Desire for a particular reason because a good
intervention is already at hand› Slow down a natural desire to “do it and get it
over with”
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Trainer’s Role During Practice
• Guide without providing all the answers› You found that the O2 sats were low. So why
were they low? Resident has COPD and no oxygen therapy.
› Resident didn’t have oxygen therapy--WHY? Because the doctor hasn’t ordered.
› The doctor hasn’t ordered– WHY? Because nursing hasn’t presented the O2 sat information.
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Trainer’s Role During Practice
• Encourage those who are having a hard time› Walk them through each WHY and praise the
smallest of achievements› Offer hints of what they might want to think
about
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Trainer’s Role During Practice Session
• Make sure they all do more than one cause and effect for the report› Practice is necessary to imprint on the brain› Many take the examples with them to guide later
attempts
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Trainer’s Role During Practice Session
• Identify those with natural ability and get them in a leadership role on the Investigation/Root Cause team
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Practice Trip-Ups
• If the answers to the questions uncovered in the investigation are not complete, cause and effect will not be able to proceed› Help staff see what they need to know before
they can start, or what they should go back to collect
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Final Step
• Meet as a large group• Each group presents• Others provide feedback with trainer’s guidance• Trainer assesses need for more instruction