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

2. 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?

3. Decisions to make When will you use RCA? Difficult issues youre 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

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

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

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