Root Cause Analysis:
Beginning the Investigation.
A Practical Application
Sue Ann Guildermann
Betsy Jeppesen
Director of Education
Empira
Vice President, Program Integrity
Stratis Health
Diane Rydrych
Linda Shell
Assistant Director, Division of Health
Policy, Minnesota Department of Health
Corporate Director, Education
Volunteers of America
Background & benchmarking


Empira: Consortium for 9 years, 28 SNFs / 5 companies
Quality 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 on

Awarded a 3-year MN DHS PIPP grant beginning
10/1/08:
~ Measured QM/QI: 1.2 Falls
2.1 Depression & Anxiety
9.1 ADLs
9.3 Room movement
~ Reduce QM/QIs: 5% first year, 15% second year, 20% third year

16 SNFs, 4 companies in DHS PIPP Fall Prevention
Root Cause Analysis: the corner
stone of the Empira Fall
Prevention Program
RCA
If you take the corner stone out, the entire structure falls down.
RCA applied to fall prevention:
• Why did the resident fall down?
• Why might the resident fall down?
Steps in Root Cause Analysis of a fall
1. Gather clues, evidence, and data, 10 Questions
~ physical environment
~ resident condition
~ system factors
2. 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
Gather clues, evidence, data
• Observation skills are critical!
– It’s easy to miss something you’re not looking for
• Gather the clues
– Look, listen, smell, touch
– Note placement of resident and surrounding
environment
• Protect area around the incident:
– Secure the room and equipment
– Observation and recording begins immediately while things are fresh
Awareness Test
Three types of causes of falls
(What are the clues and evidence you would observe for?)
• Extrinsic – physical environmental, outside
the body
• Intrinsic – resident condition, inside the body
• Systemic – operations, processes or
procedures within the facility
Extrinsic, intrinsic, systemic
causes of falls
• Extrinsic/External
– Noise (e.g., alarms, TV) environmental contrasts, bed heights,
room/bed assignment, placement of furniture and personal
items, flooring, footwear/clothing, mats, lighting
• Intrinsic/Internal
– Resident 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 loss
• Systemic
– Time of day, shift change, break times, day of week, location
of fall, type of fall, footwear, staff assignments, staffing levels,
policies and procedures
Observing the scene
10 Questions for RCA of Falls:
Directs observation process
1.
2.
3.
4.
5.
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)
6. Floor (wet, urine, shiny, carpet, etc.)
7. Footwear
8. Assistive devices
9. Glasses/hearing aids
10. Who was in the area?
Observing the scene
Investigate physical environment
Place of fall:

At bedside, 5 feet away, > 15 feet

Orthostatic, balance/gait, strength/endurance

In bathroom/at commode:

Urine or feces in toilet/commode? Urine on floor?
contents of toilet
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?
Investigate physical environment
• Noise: alarms*, TVs, talking
– *Alarms as a diagnostic tool
• Environmental contrasts
– Toilet seat, thresholds, personal items, call light
•
•
•
•
•
•
•
Bed heights
Room and bed assignment
Placement of furniture and personal items
Floor surfaces, mats
Lighting
Footwear and clothing
Assistive devices
Investigate resident condition
1.
Orthostatic B/P, vital signs, PERRL, level of
consciousness, bleeding, hand grasp
2.
The 4Ps: pain, position, personal needs,
personal items
3.
Last meds? (Diuretic?) Med review needed?
4.
Last eaten? Last voided? Sleep or rest
deprived?
5.
Labs: glucose level, Hgb and Hct (anemic),
SO2, UA/UC, X-ray, Vit D level
Root Cause Analysis
Fall Occurs
No
Assessments
and/or
interventions
Care Plan
Employee
and/or system
failure
Alterations
from resident’s
baseline
Yes
Alterations in
Environment
Why interventions sometimes
don’t work
Because they didn’t address the root causes of the fall.
Observing the scene
Questions?
Sue Ann Guildermann
Director of Education
Empira
952-259-4477
sguilder@empira.org
www.empira.org
Betsy Jeppesen
Vice President, Program Integrity
Stratis Health
952-853-8510 or 877-787-2847
bjeppesen@stratishealth.org
www.stratishealth.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
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.