Root Cause Analysis: Beginning the Investigation. A Practical Application

Diane RydrychAssistant Director, Division of HealthPolicy, Minnesota Department of Health

Betsy JeppesenVice President, Program Integrity Stratis Health

Sue Ann GuildermannDirector of EducationEmpira

Linda ShellCorporate Director, EducationVolunteers of America

Background & benchmarking Empira: Consortium for 9 years, 28 SNFs / 5 companies Quality improvement task force applies for MN DHS

Performance Incentive Payment Program (PIPP)~ Empira members investigate greatest needs for improvement

~ Falls prevention – group identifies this as the area to work on

Awarded a 3-year MN DHS PIPP grant beginning 10/1/08:

~ Measured QM/QI: 1.2 Falls 2.1 Depression & Anxiety 9.1 ADLs 9.3 Room movement

~ Reduce QM/QIs: 5% first year, 15% second year, 20% third year

16 SNFs, 4 companies in DHS PIPP Fall Prevention

Root Cause Analysis: the corner stone of the Empira Fall Prevention Program

RCA

If you take the corner stone out, the entire structure falls down.If you take the corner stone out, the entire structure falls down.

RCA applied to fall prevention:

• Why did the resident fall down?• Why might the resident fall down?

Steps in Root Cause Analysis of a fall

1. Gather clues, evidence, and data, 10 Questions

~ physical environment ~ resident condition ~ system factors

2. Investigate and determine causal relationships, FSI Report, Fall Huddle, and Fall Team meeting:

~ Why did this happen?

~ What was different this time?

~ Are there system factors that contributed?

3. Implement corrective actions (interventions) to eliminate the root causes of the problem

Gather clues, evidence, data • Observation skills are critical!

– It’s easy to miss something you’re not looking for• Gather the clues

– Look, listen, smell, touch– Note placement of resident and surrounding

environment• Protect area around the incident:

– Secure the room and equipment– Observation and recording begins immediately -

while things are fresh

Awareness Test

Three types of causes of falls(What are the clues and evidence you would observe for?)

• Extrinsic – physical environmental, outside the body

• Intrinsic – resident condition, inside the body• Systemic – operations, processes or

procedures within the facility

Extrinsic, intrinsic, systemic causes of falls• Extrinsic/External

– Noise (e.g., alarms, TV) environmental contrasts, bed heights, room/bed assignment, placement of furniture and personal items, flooring, footwear/clothing, mats, lighting

• Intrinsic/Internal– Resident activity at time of fall. B/P, O2 deprived. Balance,

endurance, sleep deprivation, medications (type and amount) distance fall occurs from transfer surface, pain, continence status (toilet contents) cognitive status, mood, depression, vision/hearing loss

• Systemic – Time of day, shift change, break times, day of week, location

of fall, type of fall, footwear, staff assignments, staffing levels, policies and procedures

Observing the scene

10 Questions for RCA of Falls:Directs observation process1. Are you okay?2. What were you trying to do?3. What was different this time?4. Position (location, distance, position, etc.)5. Surrounding area (noise, visibility, furniture, clutter,

toilet contents)6. Floor (wet, urine, shiny, carpet, etc.)7. Footwear8. Assistive devices9. Glasses/hearing aids10. Who was in the area?

Observing the scene

Investigate physical environment

Place of fall: At bedside, 5 feet away, > 15 feet

Orthostatic, balance/gait, strength/endurance In bathroom/at commode: contents of toilet Urine or feces in toilet/commode? Urine on floor?

Personal Items: Placement – easily seen? within reach? Availability – is it there? Cluttered – can’t find/can’t see it?

Equipment Service Logs Completed?Equipment Service Logs Completed? Who? When? What?

Investigate physical environment

• Noise: alarms*, TVs, talking– *Alarms as a diagnostic tool

• Environmental contrasts – Toilet seat, thresholds, personal items, call light

• Bed heights • Room and bed assignment • Placement of furniture and personal items • Floor surfaces, mats• Lighting • Footwear and clothing• Assistive devices

Investigate resident condition

1.1. Orthostatic B/P, vital signs, PERRL, level of Orthostatic B/P, vital signs, PERRL, level of

consciousness, bleeding, hand grasp consciousness, bleeding, hand grasp

2.2. The 4Ps: pain, position, personal needs,The 4Ps: pain, position, personal needs, personal items

3.3. Last meds? (Diuretic?) Med review needed?Last meds? (Diuretic?) Med review needed?

4.4. Last eaten? Last voided? Sleep or rest Last eaten? Last voided? Sleep or rest

deprived? deprived?

5.5. Labs: glucose level, Hgb and Hct (anemic), Labs: glucose level, Hgb and Hct (anemic),

SO2, UA/UC, X-ray, Vit D levelSO2, UA/UC, X-ray, Vit D level

Root Cause Analysis

Care Plan

Fall Occurs

No Yes

Assessmentsand/orinterventions

Employeeand/or systemfailure

Alterations from resident’sbaseline

Alterations inEnvironment

Why interventions sometimes don’t work

Because they didn’t address the root causes of the fall.Because they didn’t address the root causes of the fall.

Observing the scene

Questions?Sue Ann Guildermann

Director of Education

Empira

952-259-4477

sguilder@empira.org

www.empira.org

Diane Rydrych

Assistant Director

Division of Health Policy

Minnesota Department of Health

651-201-3564

Diane.rydrych@state.mn.us

www.health.state.mn.us/patientsafety

Betsy Jeppesen

Vice President, Program Integrity

Stratis Health

952-853-8510 or 877-787-2847

bjeppesen@stratishealth.org

www.stratishealth.org

Linda Shell

Corporate Director,

Education and Learning

Volunteers of America

651-503-8885

lshell@voa.org

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.