1. Root Cause Analysis: What’s In It for You?
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. Empira Fall Prevention Program: The Advantages of RCA In Action
Education
Collaboration
Data Collection & Analysis
Financial Implication
Culture Change (driven by RCA)
Hurdles & Challenges

3. 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

4. 2. Collaboration Facility Interdisciplinary Team Silos disappear
You’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 process
For solutions – not just statistics
Leaders across companies meet
On an ad hoc basis
More involvement & emphasis on program

5. 3. Data Collection & Analysis
We have a unique and robust ability to collect,
audit ,and analyze data using the RCA process
CMS Facility QM & QI Reports:
1.2 Prevalence of Falls Incidence of Depression Worsening ADLs 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

6. What does all this extra work mean to me?
“How do I benefit from this data collection and increased documentation?”

7. 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

8. 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

9. A Resident Has Fallen What Do You Do?
(Old system prior to RCA.)

10. 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.

11. 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

12. TITANIC – Why Did it Sink?

13. Every System Is Perfectly Designed to Get the Results It Achieves
We need to ask,
“Where did the system fail?”
A true story of RCA in action –
or when the system failed.

14. 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

15. 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

16. provement for people and communities.
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.