1. Root Cause Analysis: The Process
Sue Ann Guildermann
Director of Education
Empira
Betsy Jeppesen
Vice President, Program Integrity Stratis Health
Diane Rydrych
Assistant Director, Division of Health
Policy, Minnesota Department of Health
Linda Shell
Corporate Director, Education
Volunteers of America

2. Why do you think this resident falls down in about 35 minutes? Clue #1:
Here’s Vern, taking what we just learned about taking in all the information the environment can give you – what do you see – why might Vern fall?
No information given verbally – just look at picture.

3. What are we going to cover?
Considerations for conducting a Root Cause Analysis (RCA)
Steps in the RCA process

4. When RCA could be considered
Events with serious outcome for resident
Repeating incidents
Near misses/good catches
Examples:
Falls
Medication errors
Pressure ulcers
Plan of care not followed
Note that CMS has very specific definitions of near miss/good catch, clarify that we are using the term generically. Differentiate from CMS definition – this is an opportunity for learning, with less emotion/guilt.
As Dan Billings for Pathways Health framed it, a resident does not have actually reach the floor, he or she just needs to have an unexpected change in position, whatever caused the unexpected change in position.

5. When the information has been gathered…
Two approaches to RCA
An RCA team uses information from individual interviews of the multidisciplinary staff involved in the event to uncover all possible causes and systems that led to the event.
As soon as possible after the event, a group meeting that includes the multidisciplinary staff involved in the event is conducted to uncover all possible causes that led to the event.

6. Option #1 – staff interviews and separate group RCA
Staff collect initial information about the event
All staff who are on scene or have had contact in last 4 hours/shift are interviewed
Within 1 week, information is brought to the multidisciplinary committee
What happens between the scene, staff interview and the team meeting?
In your organization – will want to be clear as to who has responsibility for doing the staff interviews – is it the nurse in charge on the unit, is it the supervisor, other?
Linda – what roles are usually on the multidisciplinary committee? Are these the same people every time? Which roles vary?

7. Option #2 – RCA meeting with staff involved in the event
Information to be used in the meeting is gathered:
incident report
medical record account of the event
staff drawings/notes of the event
Time line of the event is created
Meeting is held within 48 to 72 hours

8. Other Considerations
Determine who sets up the staff interviews and/or group meeting
Consider space needed for interviews or meetings and confidentiality of the conversations
Never compromise resident safety
Group meeting within hours
Interviews begin asap, but complete within shift
Space needs to be a place where people can feel comfortable and you are mindful of the confidentiality of the information being shared and gathered.

9. Key players
Staff from departments/units directly and indirectly involved in event
Nursing administration
Medical director, physician, provider
Quality representative
Administrator
Facilitator/interviewer
Pharmacy, therapy, social work, others identified
Charge nurse, social worker, potentially housekeeping, therapy (PT/OT), possibly nursing assistant,

10. Coaching staff
Initiated prior to setting up interview/meeting if staff member has not participated before
Participation is a learning opportunity
Participation is a chance for staff to tell their story
Emphasis is on improving the system
Talking point?

11. Clue #2: This 88 year old man has atherosclerosis
Clue #2: This 88 year old man has atherosclerosis. He was admitted from the hospital 10 days ago following an MI when an angioplasty was performed and a coronary artery stent was inserted.
What are you thinking now with this additional information – does it change what you were thinking? Does it add any additional possible causes for a fall?
He has vision and hearing impairment. His daily meds include: Lopressor, Coumadin, Zocor, Lorazepam, a Multi-vitamin and a stool softener.

12. Facilitator/Interviewer
Team training/group skills
Clinical background helpful, but not required
Listening skills – uncover the story behind the event
Analytical skills – conversational/timeline versus investigation data gathering T
Facilitator should be positive, sensitive, deal with emotions, awareness of group dynamics

13. Facilitator/Interviewer (continued)
Strong boundaries
Bring people back to focus
Manage emotion (fear/anger) in the interview and at the table
Identify and draw out people
Engage entire team to give their perspective
Support everyone’s style

14. Recorder Facilitator may be recorder as well In group meetings
The facilitator is listening for to the way staff members are speaking, which may lead to further exploration of a point for finding
The recorder can then capture what they are saying
May be able to take in the non-verbals

15. Ground Rules Confidentiality Titles left at the door
All members must be active participants
No such thing as a bad question
Systems and process focus
No blaming or finger pointing
Foster creativity
“You” have the solutions

16. Telling the Story Obtain the details of what happened
What did you see, hear, etc?
Encourage people to share
Identify opportunities and gaps as the story is presented
Why, Why, Why?
What was the resident’s position? Where was the equipment? Don’t stop here.
Why didn’t the process work as expected?
What was different this time?
The early information gathering questions may not be why, but then need to get to the why…
If in a group – here are the strategies: Facilitator captures data on white flip chart
“Parking Lot” list – gives credence, but allows facilitator to move back to subject
May need to revisit interviewees, ask for a re-enactment, or gather additional information later.
If individual interviews - strategies

17. Use of triage questions in the RCA process
Helps team understand event
Assures a thorough investigation – “buckets”
Human factors
Staffing
Communication/information
Equipment/environment
Uncontrollable external factors
Training
Rules, policies, procedures
Barriers

18. Clue #3: The resident was found on the floor next to his bed.
When asked, “What were you trying to do?” He answered, “I couldn’t find my glasses. So, I got up to look for them.”
Was this the first time Vern was up looking for his glasses – why did he fall this time and not previously?

19. Continuing the RCA process
Identify factors that may have led to the event
Identify system and process gaps
Identify opportunities for improvement
Participant feedback on how to improve systems is critical
What could have been done differently?
Develop an action plan
Based on findings
With target dates
Responsible party
Monitoring/measurement plan
Follow-up

20. Spread the success/knowledge
Share with staff and administration
Go beyond interdisciplinary care team
Share learnings and collaborate with other facilities
It takes experience to move away from blaming/individual actions and towards a systems-based solution. Corrective actions should be based on systems issues, not on ‘person X didn’t follow the policy.”

21. Root Cause Analysis summary
To be thorough, an RCA must include:
Determination of human and other factors
Identification of related processes and systems that contributed to the event
Analysis of underlying causes and effects – a series of whys?

22. Questions?
Sue Ann Guildermann Director of Education Empira Diane Rydrych Assistant Director Division of Health Policy Minnesota Department of Health
Betsy Jeppesen Vice President, Program Integrity Stratis Health or Linda Shell Corporate Director, Education and Learning Volunteers of America

23. 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. 

24. Clue #4 Slide projected after lunch break.
Remember this is Vern – he had a number of clinical issues, was on a number of medications, he had a hearing and vision impairment, had gotten to get his glasses.
Here is the last clue: The resident’s wife of 62 years just died of cancer. The chaplain visited in the early evening, and pulled a chair alongside the bed to provide spiritual counseling for this grieving resident. The chaplain had left the chair along side the bed – in a place it is not usually located for Vern. Room order is key to Vern’s safety, because of the time of visit, staff had not been in the room to move the chair back into place. The chaplain was unaware of Vern’s special needs for room order.
As you learn more, your first thoughts about what the cause was might change as you learn more.
Be open to what the environment, the circumstance, the staff and the resident can tell you.