1. [Facility Name] [Presenter Name] [Date]

2. Objectives 2 After this session, you will be able to 1. describe Root Cause Analysis (RCA) and Plan-Do-Study-Act (PDSA) to your colleagues, 2. apply concepts of RCA to identify deeper causes of problems, and 3. develop an action plan to begin testing changes that will address the deeper causes.

3. Purpose of RCA RCA helps you identify the primary cause(s) of a problem, so that you can 1. determine what happened, 2. determine why it happened, and 3. figure out what to do to reduce the likelihood of it happening again. 3

4. Philosophy of RCA Focuses on systems and processes — NOT on individuals! The true problem must be understood before action is taken. i.e., causal/contributing factors or root cause(s) 4

5. RCA Uses a Systems Focus “Errors are often a result of worker carelessness.” “We need to train and motivate workers to be more careful.” “We don’t have the time or resources to really get to the bottom of this problem.” 5 “Errors are the result of defects in the system. People are only part of the process.” “We need to find out why this is happening and implement mistake-proofing so it won’t happen again.” “We need to fix it for good or it will come back.” Symptom Approach Systems Approach

6. The Root in RCA 6 The RCA approach addresses underlying causes. Symptom of the problem: the Weed above the surface (obvious) The underlying causes: the Root below the surface (not obvious) How do you kill a weed?

7. RCA Applications understand unexpected events and outcomes, examine close calls, identify trends, discern changes that will lead to improvement, and direct action plans. 7 Use RCA to

8. RCA 5-Step Process 8 Gather Initial Information and Define the Problem Fill in the GapsAnalyze/Identify the Root Cause(s) Develop Action Plan(s)Recommend and Implement Solutions(s)

9. RCA Step 1: Gather Initial Information and Define the Problem The initial information will likely be on an incident report. What are you trying to correct? – Detail who, what, when, where, how. – Brainstorm together to define a single problem. 9

10. RCA Step 1 continued… 10

11. RCA Step 2: Fill in the Gaps Consult your interdisciplinary team. Discuss other sources that might have additional information regarding the problem: – interviews/re-interviews (staff, resident, family) – documentation – observations 11

12. RCA Step 3: Analyze/Identify the Root Cause(s) What conditions allowed the problem to occur? What other factors impact the problem? What are the underlying reasons each causal factor exists? Can you impact the contributing factor? 12

13. RCA Step 3 continued… The 5-Whys is a question-asking method used to uncover the underlying causes of an event. Ask "Why?" questions until all logical causes (and/or root causes) can be identified. Uncovering the root cause leads to an Action Plan that is more likely to prevent the event from happening again. 13 THE 5-WHYs

14. RCA Step 3 continued… 14 Resident fell in room.She tripped over a chair.She didn’t see the chair.The room was dark (no nightlight).Nightlight not part of plan of care. Resident assessed as NOT at risk for falling. Why? Plan: Decide if chair is needed and move or remove the chair. Plan: Put nightlights in all the rooms. Plan: Review fall risk assessment process; update if needed. 5-Whys Example

15. RCA Step 4: Develop Action Plan Address system-level causal factors instead of people. Ensure your plan will likely keep the event from happening again. Define SMARTS objectives. 15

16. RCA Step 4 continued… SMARTS Objectives 16 S pecific M easurable A ttainable R ealistic T ime frame S upported

17. RCA Step 5: Recommend and Implement Solutions How will the solution be implemented? Who will be responsible for it? When will it be completed? Follow up to determine whether the solution was effective. Monitor on an ongoing basis and modify as necessary. 17

18. The PDSA Cycle 18 What changes are to be made? Next cycle? Analyze data Compare results to predictions Summarize what was learned Objective Predictions Plan to carry out the cycle (who, what, where, when) Plan for data collection Carry out the plan Document observations Record data How do we know changes put into place produce desired outcomes? PDSA

19. . 19 “What can we do by next Friday?” The PDSA Cycle

20. PDSA Cycle at Work 20

21. Three Fundamental Improvement Questions 21 The Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Aim Measure Change

22. Fundamental Question: Aim 22 By January 31, 2013, our facility will reduce the incidence of pressure ulcers among high-risk residents to 6% or less. Think SMARTS: S – Specific M – Measurable A – Achievable R – Realistic T – Time frame S – Supported What are we trying to accomplish?

23. Fundamental Question: Measure How will we know that a change is an improvement? 23 We will track the incidence of pressure ulcers among high-risk residents by conducting weekly skin audits (by nurse) and daily skin checks (by CNA).

24. Fundamental Question: Change What changes can we make that will lead to improvement? 24 We will document and implement turning schedules for residents with mobility limitations.

25. PDSA for Continuous Quality Improvement 25 Changes that result in improvement Learning Hunches, theories, ideas e.g., action plans or interventions Monitor and modify effectiveness.

26. What the Regulations Say… Identify contributing factors and risk(s). Evaluate and analyze contributing factors and risk(s). Implement interventions to address contributing factors and reduce risk(s). Monitor for effectiveness and modify interventions when necessary. Apply a systems approach. 26

27. What We Did Today Described RCA and PDSA. Applied concepts of RCA to identify deeper causes of a problem in your facility. Developed an action plan to begin testing changes that will address the deeper causes and set the stage for continuous improvement. 27 Plan

28. Next Steps Do Set a date for a Qsource quality improvement specialist to check in Study Look at your results Act Determine if it worked: Adapt, Adopt, Abandon 28

29. Contact Information 29 For more information on Reducing Restraints: http://www.Qsource.org This material was prepared by Qsource, the Medicare Quality Improvement Organization (QIO) for Tennessee under contract with the Centers for Medicare & Medicaid Service (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Contents do not necessarily reflect CMS policy. 12.IPC-HAC.04.008C Contact Information [Presenter Name] [Title] [Email] [Phone]