Root Cause Analysis: The Process 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

Why do you think this resident falls down in about 35 minutes? Clue #1: Here’s Vern, taking what we just learned about taking in all the information the environment can give you – what do you see – why might Vern fall? No information given verbally – just look at picture.

What are we going to cover? Considerations for conducting a Root Cause Analysis (RCA) Steps in the RCA process

When RCA could be considered Events with serious outcome for resident Repeating incidents Near misses/good catches Examples: Falls Medication errors Pressure ulcers Plan of care not followed Note that CMS has very specific definitions of near miss/good catch, clarify that we are using the term generically. Differentiate from CMS definition – this is an opportunity for learning, with less emotion/guilt. As Dan Billings for Pathways Health framed it, a resident does not have actually reach the floor, he or she just needs to have an unexpected change in position, whatever caused the unexpected change in position.

When the information has been gathered… Two approaches to RCA An RCA team uses information from individual interviews of the multidisciplinary staff involved in the event to uncover all possible causes and systems that led to the event. As soon as possible after the event, a group meeting that includes the multidisciplinary staff involved in the event is conducted to uncover all possible causes that led to the event.

Option #1 – staff interviews and separate group RCA Staff collect initial information about the event All staff who are on scene or have had contact in last 4 hours/shift are interviewed Within 1 week, information is brought to the multidisciplinary committee What happens between the scene, staff interview and the team meeting? In your organization – will want to be clear as to who has responsibility for doing the staff interviews – is it the nurse in charge on the unit, is it the supervisor, other? Linda – what roles are usually on the multidisciplinary committee? Are these the same people every time? Which roles vary?

Option #2 – RCA meeting with staff involved in the event Information to be used in the meeting is gathered: incident report medical record account of the event staff drawings/notes of the event Time line of the event is created Meeting is held within 48 to 72 hours

Other Considerations Determine who sets up the staff interviews and/or group meeting Consider space needed for interviews or meetings and confidentiality of the conversations Never compromise resident safety Group meeting within 48-72 hours Interviews begin asap, but complete within shift Space needs to be a place where people can feel comfortable and you are mindful of the confidentiality of the information being shared and gathered.

Key players Staff from departments/units directly and indirectly involved in event Nursing administration Medical director, physician, provider Quality representative Administrator Facilitator/interviewer Pharmacy, therapy, social work, others identified Charge nurse, social worker, potentially housekeeping, therapy (PT/OT), possibly nursing assistant,

Coaching staff Initiated prior to setting up interview/meeting if staff member has not participated before Participation is a learning opportunity Participation is a chance for staff to tell their story Emphasis is on improving the system Talking point?

Clue #2: This 88 year old man has atherosclerosis Clue #2: This 88 year old man has atherosclerosis. He was admitted from the hospital 10 days ago following an MI when an angioplasty was performed and a coronary artery stent was inserted. What are you thinking now with this additional information – does it change what you were thinking? Does it add any additional possible causes for a fall? He has vision and hearing impairment. His daily meds include: Lopressor, Coumadin, Zocor, Lorazepam, a Multi-vitamin and a stool softener.

Facilitator/Interviewer Team training/group skills Clinical background helpful, but not required Listening skills – uncover the story behind the event Analytical skills – conversational/timeline versus investigation data gathering T Facilitator should be positive, sensitive, deal with emotions, awareness of group dynamics

Facilitator/Interviewer (continued) Strong boundaries Bring people back to focus Manage emotion (fear/anger) in the interview and at the table Identify and draw out people Engage entire team to give their perspective Support everyone’s style

Recorder Facilitator may be recorder as well In group meetings The facilitator is listening for to the way staff members are speaking, which may lead to further exploration of a point for finding The recorder can then capture what they are saying May be able to take in the non-verbals

Ground Rules Confidentiality Titles left at the door All members must be active participants No such thing as a bad question Systems and process focus No blaming or finger pointing Foster creativity “You” have the solutions

Telling the Story Obtain the details of what happened What did you see, hear, etc? Encourage people to share Identify opportunities and gaps as the story is presented Why, Why, Why? What was the resident’s position? Where was the equipment? Don’t stop here. Why didn’t the process work as expected? What was different this time? The early information gathering questions may not be why, but then need to get to the why… If in a group – here are the strategies: Facilitator captures data on white flip chart “Parking Lot” list – gives credence, but allows facilitator to move back to subject May need to revisit interviewees, ask for a re-enactment, or gather additional information later. If individual interviews - strategies

Use of triage questions in the RCA process Helps team understand event Assures a thorough investigation – “buckets” Human factors Staffing Communication/information Equipment/environment Uncontrollable external factors Training Rules, policies, procedures Barriers

Clue #3: The resident was found on the floor next to his bed. When asked, “What were you trying to do?” He answered, “I couldn’t find my glasses. So, I got up to look for them.” Was this the first time Vern was up looking for his glasses – why did he fall this time and not previously?

Continuing the RCA process Identify factors that may have led to the event Identify system and process gaps Identify opportunities for improvement Participant feedback on how to improve systems is critical What could have been done differently? Develop an action plan Based on findings With target dates Responsible party Monitoring/measurement plan Follow-up

Spread the success/knowledge Share with staff and administration Go beyond interdisciplinary care team Share learnings and collaborate with other facilities It takes experience to move away from blaming/individual actions and towards a systems-based solution. Corrective actions should be based on systems issues, not on ‘person X didn’t follow the policy.”

Root Cause Analysis summary To be thorough, an RCA must include: Determination of human and other factors Identification of related processes and systems that contributed to the event Analysis of underlying causes and effects – a series of whys?

Questions? Sue Ann Guildermann Director of Education Empira 952-259-4477 sguilder@empira.org www.empira.org Diane Rydrych Assistant Director Division of Health Policy Minnesota Department of Health 651-201-3564 Diane.rydrych@state.mn.us www.health.state.mn.us/patientsafety Betsy Jeppesen Vice President, Program Integrity Stratis Health 952-853-8510 or 877-787-2847 bjeppesen@stratishealth.org www.stratishealth.org Linda Shell Corporate Director, Education and Learning Volunteers of America 651-503-8885 lshell@voa.org

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. 

Clue #4 Slide projected after lunch break. Remember this is Vern – he had a number of clinical issues, was on a number of medications, he had a hearing and vision impairment, had gotten to get his glasses. Here is the last clue: The resident’s wife of 62 years just died of cancer. The chaplain visited in the early evening, and pulled a chair alongside the bed to provide spiritual counseling for this grieving resident. The chaplain had left the chair along side the bed – in a place it is not usually located for Vern. Room order is key to Vern’s safety, because of the time of visit, staff had not been in the room to move the chair back into place. The chaplain was unaware of Vern’s special needs for room order. As you learn more, your first thoughts about what the cause was might change as you learn more. Be open to what the environment, the circumstance, the staff and the resident can tell you.