1. Be the voice of root cause analysis- The role of social workers in promoting root cause analysis and resident-directed care
Amy Ruedinger, RN RAC-CT Pinnacle Innovative Healthcare Solutions
Prepared for Leading Age Oklahoma
Spring 2015

2. Objectives
Evaluate the components of root cause analysis as it pertains to quality measures, quality assurance, CAAs and overall documentation
Gain tips to promote effective documentation
Examine the connection between MDS, CAAs/root cause analysis and the plan of care
Discuss the benefits and potential challenges of providing person-directed cares.

3. Root Cause Analysis Define root cause analysis “WHY?” “SO WHAT??” “
WHY IS THIS IMPORTANT?”
How does it impact my decision/care planning
The 5 Whys
The Fishbone diagram
Examples
Dx, Meds. Labs,
How do these findings help to explain the concern/behavior/mood
EX: UTI and behaviors

4. Root Cause Analysis and Quality Assurance
Quality Measures
Short stay residents who newly received an antipsychotic medication
Residents with depressive symptoms (long stay)
Long stay residents who received an antipsychotic medication
(Surveyor QM) Residents with behaviors affecting others
How are they determined?
Based on MDS coding
QM User’s manual

5. Root Cause Analysis
&
Quality Assurance

6. Root Cause Analysis and Quality Assurance
Root cause analysis and the QA Process
Determine which QMs triggered
Investigate why the concern triggered
MDS indicator and why it was coded
Concerns, precipitating factors, trends
Effective interventions
Develop a plan to manage the concern

7. Root cause analysis and Quality Assurance
Root Cause Analysis and the QA process
Example: QM triggers for Use of antipsychotic medication ( long and short stay residents)
Which medications?
What is the behavior or condition that warrants use of the medication?
Alternatives to medications?
Dose reductions?
Have we tried any other approaches ( non-pharmacological- including activity interventions)
What has been effective?
If not, have we assessed and care planned for any possible side effects of the medications

8. Root cause analysis and Quality Assurance
Root Cause Analysis and the QA process
Example: QM triggers for depressive symptoms
Example: QM triggers for “Behaviors affecting others”
Which resident/s are triggering?
Which behaviors/symptoms?
Why are the residents having these behaviors/symptoms? ( individually, facility wide)
What precipitates the behavior/condition
What can we do to manage the behaviors/symptoms?
Is the care plan effective and appropriate?

9. Root Cause Analysis & Effective Documentation

10. Root Cause Analysis and Effective Documentation
Standards of Practice related to documentation
Proves that facility was providing care it was paid to provide (think Med A charting)
Required part of the resident’s care-validates that care was given and standards of care were met
Essential element of communication
Reflective of resident response to cares and actions taken to rectify unsatisfactory response
Timely and completed only during or after giving cares
Chronological
Internally consistent

11. Root Cause Analysis and Effective Documentation
Charting consistency and objectivity
Documentation should reveal consistent interventions among disciplines
Consistency within the resident record
Quality of content, not quantity of words
Allegations about cares or comments about staff members should not be in charting
Avoid charting about staffing shortages (tx not done due to lack of staff)

12. Documentation Standards
Documentation tips: What to document
Assessments, observations, concerns, interventions-cares and treatments
Incorporating critical thinking and root case analysis:
What happened and why
Note action taken, resident response and evaluation
Critical thinking/root cause analysis—did it work? If not, what next?

13. Documentation Standards
Documentation tips: How to document
Be specific when describing behavior( not: “unruly” or “agitated” or “uncooperative”)
This will help to paint an accurate and objective picture of what is happening with the resident
Document precipitating factors, what makes it better and what makes it worse
Incorporating root cause analysis
Document cares and interventions
Document resident response to cares and interventions

14. Documentation Standards
Documentation tips: Cares/treatment/intervention
Charting regarding cares/interventions and responses should be consistent with resident status
Describe resident response to any teaching, including understanding. List specific information given
Document all safety precautions taken to protect resident

15. Documentation Standards
Care Plan Documentation
Care plan should be updated when there is a change in resident status or resident orders
New interventions when there are new mood/behavioral concerns
If new med, is there an intervention needed to monitor effectiveness or side effects?
If interventions have been ineffective in past, probably should not be repeated (especially in case of falls/behaviors )
Incorporate root cause analysis to help determine why the interventions used previously were not effective and plan for other interventions that may be more appropriate
Care plan should match MDS and the resident’s current status
Ex: If MDS reflects short term memory deficit, reminder to use call light or call for assistance with tasks or activities may not be appropriate

16. Root Cause Analysis CAAS & Care Planning

17. CAAs
CAA process guides the ID team through a comprehensive assessment of the resident’s functional status
Each CAA must be addressed, but may not need to be care planned
CAA documentation should address the reason that the CAA triggered
Identify:
Areas that warrant intervention
Areas that impact resident function
How to minimize decline and avoid functional complications
Address palliative care, including symptom relief and pain management

18. CAAs “Chart your thinking” ROOT CAUSE ANALYSIS/CAAs
Documentation should include:
Nature of the condition
Underlying causes-diagnoses, conditions, meds, labs
Contributing factors-complications
Unique risk factors-complications, justification for care planning or not care planning
Need for referrals
Decision to proceed with care planning

19. CAAs CAAs: Discussion and tips Cognitive CAA Communication CAA
Mood CAA
Behavior CAA
Psychosocial CAA

20. CAAs Areas of concern for each CAA:
Current status or level of function
Reason for the CAA to be triggering
Recent changes- improvements or declines
Precipitating factors /What makes the situation better or worse
Comparison to most recent prior MDS-BIMS and Mood scores, etc
Diagnoses and conditions
Meds, labs, treatments
Need for referrals
Other areas
Care Plan-develop, continue, revise

21. CAAs and Care Planning Care Planning
Address areas as triggered in the CAA ( unless you decided not to proceed with care plan)
Combine care plan areas when it makes sense
Care plan should promote highest level of function
Goals for improvement, prevention of complication or decline, palliative goals, maintenance goals
Care plan can address resident strengths and preferences
Involve resident and family or legal representative

22. CAAs and Care Planning Care Planning
Use the information you learned in the MDS assessments, interveiws, CAAs and root cause analysis to develop a plan of care that is specific and effective for that resident
Incorporate the resident’s goals and preferences as much as possible
Incorporate information from the interviews
Focus on Person- directed cares
Ensure that care plans contain individualized approaches
Care plans are a working document and should be accessible to all staff
Ensure that the care plan is consistent with the information and preferences noted in MDS and CAAs

23. Person Directed Care
Questions to consider when planning for person-directed care
What kind of help does the resident need and/or want?
When would s/he like the help?
What would s/he prefer to do for themselves?
What has worked or not worked in the past and why?
How will this affect care planning now?

24. Person Directed Care
Culture Change, Care planning and Person-directed Care:
Linda Bump is one the pioneers of the culture change movement
“Bump’s Law” can be the basis and driving force behind every decision- big or small.
What does the resident want?
How did the resident do it at his/her previous home?
How do you do it at home?
How should we do it here?

25. Envision….Person-directed cares
Dining
Medications
Cares
Activities
Decorations and Furnishings
Policies
Staffing
Expanded Social History
Communication with families regarding the philosophy of culture change
Dining- style of service, menu choices, dining times, food available at all times in a variety of locations, ability for residents and tenants to help with meal prep, ability of residents and tenants to have guests for meals, staff eating with the tenants. ( more on that in the next session)
Waking times- this needs to be addressed in tandem with dining and meds since these three areas are interdependent and will need to be planned for together.
Medications- choices as to whether to take meds, medication times- fewer times=fewer interruptions in their day, meds in rooms versus med carts. Policy regarding giving meds in the dining rooms.
Cares- choices about when, if and how assistance will be offered
Activities- daily opportunities for meaningful, purposeful engagement.

26. Envision….Person-directed cares
Residents choosing and planning activities
Natural waking times
Easier medication administration
Staff self scheduling
Staff eating with residents
Residents decorating their living and common spaces
Meaningful engagement every day
Now as we move forward, I would like you to envision some of the possibilities…..
How would your facility look and feel and operate if :
The residents decided on the type and frequency of activity programs
You encouraged residents to sleep until they awoke and then you gave them their medications and meals
Meals and snacks were available at all times in a variety of locations, and residents were encouraged to share with their guests
Residents could “host” gatherings of family/friends and share treats-just like at home
You simplified the med delivery times, and eliminated unnecessary meds
The staff was empowered to set up their own schedules based on resident needs
You encouraged the staff to sit down and enjoy the meals with the residents
Example from Pigeon Falls
What is residents helped with meal prep?

27. Envision….Person-directed cares
“Person-directed care means we get out of the way when they express their preferences”
Put the resident at the center
Include the family
Educate
Know Best Practices
Write and implement clear policies regarding choice
Resident directed care means we get out of the way when they express their preferences.
Always—the resident or tenant is at the center of everything we do and every policy or practice that we implement.
Bump’s Law
We invite the family into the process- providing education and support within the framework of always supporting the resident or tenant first.
In the RCAC---Negotiated risk agreements
We provide education for the staff, tenant and family so everyone is aware of the risks-both upside and downside risks.
Educate the family and staff about elder’s decision making strategies and risk tolerance.
Establish staff competencies that reflect the tenets of culture change and honoring personhood.
It is imperative that we keep up with the latest research and trends, as well as the regulations so that we are confident in our knowledge of best practices. This will help us to be confident when we educate everyone, it will also enable to implement effective policies. Knowledge of the newest research and best practices in any given area will also give us an idea of what to look for and how to manage the possible risks if the resident chooses not to follow recommendations.

28. Person-Directed Cares
Tips for incorporating Person-Directed Care into the resident’s plan of care and daily life
Challenges –solutions
Suggestions and sharing from the participants

29. Thank You
Amy Ruedinger, RN, RAC-CT Pinnacle Innovative Healthcare Solutions, LLC (920) ~Facilitating Peak Performance in Senior Health and Housing ~