Presentation on theme: "Root Cause Analysis: What’s In It for You?"— Presentation transcript:
1Root Cause Analysis: What’s In It for You? Sue Ann GuildermannDirector of EducationEmpiraBetsy JeppesenVice President, Program Integrity Stratis HealthDiane RydrychAssistant Director, Division of HealthPolicy, Minnesota Department of HealthLinda ShellCorporate Director, EducationVolunteers of America
2Empira Fall Prevention Program: The Advantages of RCA In Action EducationCollaborationData Collection & AnalysisFinancial ImplicationCulture Change (driven by RCA)Hurdles & Challenges
31. EducationAll staff, all departments receive education on RCA – everyone learns the processOwnership in the RCA process by all staff – both leadership and direct staff – one department does not do it allMulti-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 careOther stakeholders: Residents, Families, MDs & NPs, MDH surveyors, LTC providers
42. Collaboration Facility Interdisciplinary Team Silos disappear You’re not solving the problems aloneShared decision-making processIt’s not just a nursing program/process anymoreSilos disappearQA focuses on RCA processFor solutions – not just statisticsLeaders across companies meetOn an ad hoc basisMore involvement & emphasis on program
53. Data Collection & Analysis We have a unique and robust ability to collect,audit ,and analyze data using the RCA processCMS Facility QM & QI Reports:1.2 Prevalence of Falls Incidence of Depression Worsening ADLs Worsening Room MovementFall Scene Investigation Report (FSI)Falls Monthly Tracking Report & Fall Summary ReportResident Falls per 1,000 daysAnnual CMS surveys & OHFC complaints
6What does all this extra work mean to me? “How do I benefit from this data collection and increased documentation?”
7Results* (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
84. Financial Implications Cost of a Fall:Clinical care following fall = $10,000 - $24,000Takes more staff time and more staffing hoursCMS & OHFC follow-upsDecline in condition: ADLs, mood, cognitiveMore legal expensesDiagnostic requirementsPoor public relations and reputationMore equipment needsEducation and trainingMore risk managementBenefits of Not Falling:Less staff time for follow up care when no fall occursLess CMS & OHFC oversightHealthier resident conditionFewer legal expensesLess stress on resourcesImproved job satisfaction and retentionImproved customer relationsImproved reputation for quality careLess risk management
9A Resident Has Fallen What Do You Do? (Old system prior to RCA.)
105. 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.
11Tip of the Iceberg We only see the tip of what is really there Keep lookingKeep digging until you find the real cause(s) of this particular fall, this particular incident
13Every 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.
14Hurdles and Challenges RCA competencyRoot Cause Analysis vs. Just Tell Me What To DoScatter gun approach to interventions vs. matching interventions to root cause of fallStaff resists changeA tendency to return to the old ways of doing thingsSustainability: building systems (redundancy)It becomes part of the cultureNot just a nursing program any moreGet everyone on boardOSHA Safe Patient Handling vs. reduction inresident independence = falls
15Questions?Sue Ann Guildermann , Director of Education, Empira Diane Rydrych, Assistant Director, Division of Health Policy, Minnesota Department of HealthBetsy Jeppesen Vice President, Program Integrity Stratis Health or Linda Shell Corporate Director, Education and Learning Volunteers of America
16provement 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 facilitatingprovement for people and communities.