Presentation on theme: "Root Cause Analysis: Beginning the Investigation"— Presentation transcript:
1 Root Cause Analysis: Beginning the Investigation Root Cause Analysis: Beginning the Investigation. A Practical ApplicationSue Ann GuildermannDirector of EducationEmpiraBetsy JeppesenVice President, Program Integrity Stratis HealthDiane RydrychAssistant Director, Division of HealthPolicy, Minnesota Department of HealthLinda ShellCorporate Director, EducationVolunteers of America
3 Background & benchmarking Empira: Consortium for 9 years, 28 SNFs / 5 companiesQuality improvement task force applies for MN DHS Performance Incentive Payment Program (PIPP)~ Empira members investigate greatest needs for improvement~ Falls prevention – group identifies this as the area to work onAwarded a 3-year MN DHS PIPP grant beginning 10/1/08:~ Measured QM/QI: Falls Depression & Anxiety ADLs Room movement~ Reduce QM/QIs: 5% first year, 15% second year, 20% third year16 SNFs, 4 companies in DHS PIPP Fall Prevention
4 Root Cause Analysis: the corner stone of the Empira Fall Prevention Program RCAIf you take the corner stone out, the entire structure falls down.
5 RCA applied to fall prevention: Why did the resident fall down?Why might the resident fall down?
6 Steps in Root Cause Analysis of a fall 1. Gather clues, evidence, and data, 10 Questions ~ physical environment ~ resident condition ~ system factors2. Investigate and determine causal relationships, FSI Report, Fall Huddle, and Fall Team meeting:~ Why did this happen?~ What was different this time?~ Are there system factors that contributed?3. Implement corrective actions (interventions) to eliminate the root causes of the problem
7 Gather clues, evidence, data Observation skills are critical!It’s easy to miss something you’re not looking forGather the cluesLook, listen, smell, touchNote placement of resident and surrounding environmentProtect area around the incident:Secure the room and equipmentObservation and recording begins immediately - while things are freshThis probably needs to be reworded – this slide is off the top of my head this a.m.
9 Three types of causes of falls (What are the clues and evidence you would observe for?) Extrinsic – physical environmental, outside the bodyIntrinsic – resident condition, inside the bodySystemic – operations, processes or procedures within the facility
10 Extrinsic, intrinsic, systemic causes of falls Extrinsic/ExternalNoise (e.g., alarms, TV) environmental contrasts, bed heights, room/bed assignment, placement of furniture and personal items, flooring, footwear/clothing, mats, lightingIntrinsic/InternalResident activity at time of fall. B/P, O2 deprived. Balance, endurance, sleep deprivation, medications (type and amount) distance fall occurs from transfer surface, pain, continence status (toilet contents) cognitive status, mood, depression, vision/hearing lossSystemicTime of day, shift change, break times, day of week, location of fall, type of fall, footwear, staff assignments, staffing levels, policies and proceduresSue Ann – does it make sense to have this slide here, or should it be later? I was thinking they’d go through the first picture, then you’d talk about this, then they’d do the second picture as a large group. Does that make sense?Note: Not sure if we need to reword anything on this slide, so there’s no confusion about ‘systemic causes’ versus the ‘system factors’ that we’ll be talking about elsewhere. Some are the same (policies, staffing, etc), but some are a bit different.
12 10 Questions for RCA of Falls: Directs observation process Are you okay?What were you trying to do?What was different this time?Position (location, distance, position, etc.)Surrounding area (noise, visibility, furniture, clutter, toilet contents)Floor (wet, urine, shiny, carpet, etc.)FootwearAssistive devicesGlasses/hearing aidsWho was in the area?Not sure if this slide is in the right place…..
14 Investigate physical environment Place of fall:At bedside, 5 feet away, > 15 feetOrthostatic, balance/gait, strength/enduranceIn bathroom/at commode: contents of toiletUrine or feces in toilet/commode? Urine on floor?Personal Items:Placement – easily seen? within reach?Availability – is it there?Cluttered – can’t find/can’t see it?Equipment Service Logs Completed?Who? When? What?
15 Investigate physical environment Noise: alarms*, TVs, talking*Alarms as a diagnostic toolEnvironmental contrastsToilet seat, thresholds, personal items, call lightBed heightsRoom and bed assignmentPlacement of furniture and personal itemsFloor surfaces, matsLightingFootwear and clothingAssistive devices
16 Investigate resident condition Orthostatic B/P, vital signs, PERRL, level of consciousness, bleeding, hand graspThe 4Ps: pain, position, personal needs, personal itemsLast meds? (Diuretic?) Med review needed?Last eaten? Last voided? Sleep or rest deprived?Labs: glucose level, Hgb and Hct (anemic), SO2, UA/UC, X-ray, Vit D levelDo we want to add anything about change in status, or whether something has happened in the person’s life that might have contributed to the event?
17 Root Cause Analysis Fall Occurs No Yes Care Plan Assessments and/or interventionsEmployeeand/or systemfailureAlterationsfrom resident’sbaselineAlterations inEnvironment
18 Why interventions sometimes don’t work Because they didn’t address the root causes of the fall.
20 Questions?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
21 Protecting, maintaining and improving the health of all Minnesotans. Stratis Health is a nonprofit organization that leads collaboration andinnovation in health care quality and safety, and serves as a trustedexpert in facilitating improvement for people and communities.