root cause analysis: whats in it for you? diane rydrych assistant director, division of health...

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

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

provement for people and communities.