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2012 User Group. 22 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Harness the Power of Root Cause Analysis June 19, 2012 2:30-3:45 Joyce Rutherford.

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Presentation on theme: "2012 User Group. 22 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Harness the Power of Root Cause Analysis June 19, 2012 2:30-3:45 Joyce Rutherford."— Presentation transcript:

1 2012 User Group

2 22 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Harness the Power of Root Cause Analysis June 19, :30-3:45 Joyce Rutherford Donner

3 33 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Teaching Root Cause Critical Thinking Skills Natural Talent Long, Hard Slog

4 44 | 4/29/2015 | © eHealth Data Solutions 2012 User Group

5 55 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Important First Step Investigation Phase: Researching, Asking Questions Re-enactment

6 66 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Results of a Good Investigation Include Thoughts About: Systems breakdown Training needs Resident needs Environmental needs

7 77 | 4/29/2015 | © eHealth Data Solutions 2012 User Group What is the Root Cause? Root Cause - a specific underlying reason › Can be reasonably identified › Management has control to fix, change, or care plan › Facilitates development of actions for prevention The process of choosing a Root Cause › Will identify “Causal Factors,” contributors that, if eliminated, would have prevented and/or reduced the severity the occurrence. › Is not a 1-person job.

8 88 | 4/29/2015 | © eHealth Data Solutions 2012 User Group

9 99 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Methods

10 10 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Ishikawa (Fishbone) Diagram

11 11 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Cause and Effect Diagram

12 12 | 4/29/2015 | © eHealth Data Solutions 2012 User Group WHY??

13 13 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Fall from W/C Trying to get into bed by himself Staff didn’t find out if he wanted to go to bed Aphasic and doesn’t have communication board Res. can’t communi- cate Confusion d/t low O2 sat No oxygen therapy Physician has not ordered Alarm did not sound Battery dead No maintenance program No data re: O2 sats No SLP orders

14 14 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Asking “WHY” Without Completing The Investigation Can Lead To Dead Ends Resident fell › Why Because she tried to stand up without assistance › Why I don’t know › Why don’t you know? › I didn’t ask her or the staff

15 15 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Practice Using one report so all are working on the same problem › Groups of 3-4 › Flip chart paper and markers OR post-it notes › Space to meet as a group Create a cause and effect diagram

16 16 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Trainer’s Role During Practice Session Assist with the “why” process to prevent jumping to conclusions › Logical conclusion and not what the first impression was › Desire for a particular reason because a good intervention is already at hand › Slow down a natural desire to “do it and get it over with”

17 17 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Trainer’s Role During Practice Guide without providing all the answers › You found that the O2 sats were low. So why were they low? Resident has COPD and no oxygen therapy. › Resident didn’t have oxygen therapy--WHY? Because the doctor hasn’t ordered. › The doctor hasn’t ordered– WHY? Because nursing hasn’t presented the O2 sat information.

18 18 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Trainer’s Role During Practice Encourage those who are having a hard time › Walk them through each WHY and praise the smallest of achievements › Offer hints of what they might want to think about

19 19 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Trainer’s Role During Practice Session Make sure they all do more than one cause and effect for the report › Practice is necessary to imprint on the brain › Many take the examples with them to guide later attempts

20 20 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Trainer’s Role During Practice Session Identify those with natural ability and get them in a leadership role on the Investigation/Root Cause team

21 21 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Practice Trip-Ups If the answers to the questions uncovered in the investigation are not complete, cause and effect will not be able to proceed › Help staff see what they need to know before they can start, or what they should go back to collect

22 22 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Final Step Meet as a large group Each group presents Others provide feedback with trainer’s guidance Trainer assesses need for more instruction

23 23 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Questions


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