root cause analysis: next steps diane rydrych assistant director, division of health policy,...
TRANSCRIPT
Root Cause Analysis: Next Steps
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
Where do we go from here?• We understand what RCA is and how to facilitate
an RCA…..now what?• Planning for implementation
Buy-inBuy-in DecisionsDecisions Education/trainingEducation/training
Getting buy-in• Need commitment from your organization
– Who makes the decisions? – What do they need to know/understand?– When & how will they decide?– What do you need them to commit – resources,
time, moral support?– Who is going to be responsible for making sure
that corrective actions happen – that you are following through?
Decisions to make• When will you use RCA?
– Difficult issues you’re struggling with?– Highest risk for injury or death?– Frequency?
• What criteria should you use?• What are the ramifications?
– Resource needs– Education/training– Frequency of RCA
Staff Education• Facilitator training• Just in time training for staff• Role of medical director, pharmacy, hospice,
others who may be involved• Orientation
Resources• Reporting forms• Tools/visuals for timelines or root cause
diagrams• Training forms for staff
The hard part• Doing the RCA is not the most difficult part…• The challenge comes from committing to your
staff that you’re going to do things in a different way & truly examine root causes.
• You are asking for their trust. Are you going to follow through?
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 improvement for people and communities.