1. Root Cause Analysis: Next Steps
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. Where do we go from here?
We understand what RCA is and how to facilitate an RCA…..now what?
Planning for implementation
Buy-in
Decisions
Education/training

3. Getting buy-in Need commitment from your organization
Who makes the decisions?
What do they need to know/understand?
When & how will they decide?
What do you need them to commit – resources, time, moral support?
Who is going to be responsible for making sure that corrective actions happen – that you are following through?

4. Decisions to make When will you use RCA? What criteria should you use?
Difficult issues you’re struggling with?
Highest risk for injury or death?
Frequency?
What criteria should you use?
What are the ramifications?
Resource needs
Education/training
Frequency of RCA

5. Staff Education Facilitator training Just in time training for staff
Role of medical director, pharmacy, hospice, others who may be involved
Orientation

6. Resources Reporting forms
Tools/visuals for timelines or root cause diagrams
Training forms for staff

7. The hard part Doing the RCA is not the most difficult part…
The challenge comes from committing to your staff that you’re going to do things in a different way & truly examine root causes.
You are asking for their trust. Are you going to follow through?

8. 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

9. 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 improvement for people and communities.