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Root Cause Analysis: What’s In It for You?
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
Empira Fall Prevention Program: The Advantages of
RCA In Action
• Education• Collaboration• Data Collection & Analysis• Financial Implication• Culture Change (driven by RCA)• Hurdles & Challenges
1. Education
• All staff, all departments receive education on RCA – everyone learns the process
• Ownership in the RCA process by all staff – both leadership and direct staff – one department does not do it all
• Multi-factorial approach to falls prevention – not just a clinical approach!
• Share information: we all learn from each other – from our mistakes, triumphs, successes, errors – to format it into a standard of care
• Other stakeholders: Residents, Families, MDs & NPs, MDH surveyors, LTC providers
2. 2. Collaboration
Facility Interdisciplinary TeamYou’re not solving the problems alone
Shared decision-making process
It’s not just a nursing program/process anymore
Silos disappear
QA focuses on RCA processFor solutions – not just statistics
Leaders across companies meet On an ad hoc basis
More involvement & emphasis on program
3. Data Collection & AnalysisWe have a unique and robust ability to collect, We have a unique and robust ability to collect,
audit ,and analyze data using the RCA processaudit ,and analyze data using the RCA process
CMS Facility QM & QI Reports:
1.2 Prevalence of Falls 2.1 Incidence of Depression
9.1 Worsening ADLs 9.3 Worsening Room Movement
Fall Scene Investigation Report (FSI)
Falls Monthly Tracking Report & Fall Summary Report
Resident Falls per 1,000 days
Annual CMS surveys & OHFC complaints
What does all this extra work mean to me?
?
““How do I benefit How do I benefit from this data from this data collection and collection and increased increased documentation?”documentation?”
Results* (after 18 months))
QI 1.2: Prevalence of Falls (number of residents who have fallen) – decreased by 15%
QI 2.1: Incidence of Depression – decreased 15%
QI 9.1: Worsening ADLs – decreased 12%
QI 9.3: Worsening Room Movement – decreased 13%
Falls per 1,000 resident days (number of falls that occurred) – decreased by 14%
Recurrent Falls Tracking – double digits to single digit numbers
* Compared to baseline stats prior to start of program
4. Financial Implications• Cost of a Fall:
– Clinical care following fall = $10,000 - $24,000
– Takes more staff time and more staffing hours
– CMS & OHFC follow-ups– Decline in condition: ADLs,
mood, cognitive– More legal expenses– Diagnostic requirements– Poor public relations and
reputation– More equipment needs– Education and training– More risk management
• Benefits of Not Falling:– Less staff time for follow up
care when no fall occurs– Less CMS & OHFC oversight– Healthier resident condition – Fewer legal expenses – Less stress on resources– Improved job satisfaction
and retention– Improved customer relations– Improved reputation for
quality care– Less risk management
A Resident Has Fallen What Do You Do?
(Old system prior to RCA.)
5. Culture Change (driven by RCA)
RCA transforms a culture that reacts to problems into a culture that solves problems before they escalate.
Aiming performance improvement operations at root causes is more effective than merely treating the symptoms of problems.
Problems are best solved by eliminating and correcting the root causes, as opposed to merely addressing the obvious symptoms with scatter-gun approaches to solutions.
RCA is performed with conclusions and causes and supported by documented, evidence-based practice.
Tip of the Iceberg
We only see the tip of what is really there
Keep looking
Keep digging until you find the real cause(s) of this particular fall, this particular incident
TITANIC – Why Did it Sink?
Every System Is Perfectly Designed to Get the Results It
AchievesWe need to ask,“Where did the system fail?”
A true story of RCA in action – A true story of RCA in action – or when the system failed. or when the system failed.
Hurdles and Challenges• RCA competency
– Root Cause Analysis vs. Just Tell Me What To Do
– Scatter gun approach to interventions vs. matching interventions to root cause of fall
• Staff resists change – A tendency to return to the old ways of doing things
• Sustainability: building systems (redundancy) – It becomes part of the culture
• Not just a nursing program any more– Get everyone on board
• OSHA Safe Patient Handling vs. reduction in
resident independence = falls
Questions?Sue Ann Guildermann ,
Director of Education,
Empira
952-259-4477
www.empira.org
Diane Rydrych,
Assistant Director,
Division of Health Policy,
Minnesota Department of Health
651-201-3564
www.health.state.mn.us/patientsafety
Betsy Jeppesen
Vice President, Program Integrity
Stratis Health
952-853-8510 or 877-787-2847
www.stratishealth.org
Linda Shell
Corporate Director,
Education and Learning
Volunteers of America
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
provement for people and communities.
