Root Cause Analysis:
What’s In It for You?
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
Empira Fall Prevention
Program: The Advantages of
RCA In Action
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Education
Collaboration
Data Collection & Analysis
Financial Implication
Culture Change (driven by RCA)
Hurdles & Challenges
1. Education
• All staff, all departments receive education on
RCA – everyone learns the process
• Ownership in the RCA process by all staff – both
leadership and direct staff – one department does
not do it all
• Multi-factorial approach to falls prevention – not
just a clinical approach!
• Share information: we all learn from each other –
from our mistakes, triumphs, successes, errors –
to format it into a standard of care
• Other stakeholders: Residents, Families, MDs &
NPs, MDH surveyors, LTC providers
2. Collaboration
Facility Interdisciplinary Team
You’re not solving the problems alone
Shared decision-making process
It’s not just a nursing program/process anymore
Silos disappear
QA focuses on RCA process
For solutions – not just statistics
Leaders across companies meet
On an ad hoc basis
More involvement & emphasis on program
3. Data Collection & Analysis
We have a unique and robust ability to collect,
audit ,and analyze data using the RCA process
CMS Facility QM & QI Reports:
1.2 Prevalence of Falls
2.1 Incidence of Depression
9.1 Worsening ADLs
9.3 Worsening Room Movement
Fall Scene Investigation Report (FSI)
Falls Monthly Tracking Report & Fall Summary Report
Resident Falls per 1,000 days
Annual CMS surveys & OHFC complaints
What does all this extra work
mean to me?
“How do I benefit
from this data
collection and
increased
documentation?”
?
Results* (after 18 months)
QI 1.2: Prevalence of Falls (number of residents
who have fallen) – decreased by 15%
QI 2.1: Incidence of Depression – decreased 15%
QI 9.1: Worsening ADLs – decreased 12%
QI 9.3: Worsening Room Movement – decreased 13%
Falls per 1,000 resident days (number of falls that
occurred) – decreased by 14%
Recurrent Falls Tracking – double digits to single digit
numbers
* Compared to baseline stats prior to start of program
4. Financial Implications
• Cost of a Fall:
– Clinical care following fall =
$10,000 - $24,000
– Takes more staff time and
more staffing hours
– CMS & OHFC follow-ups
– Decline in condition: ADLs,
mood, cognitive
– More legal expenses
– Diagnostic requirements
– Poor public relations and
reputation
– More equipment needs
– Education and training
– More risk management
• Benefits of Not Falling:
– Less staff time for follow up
care when no fall occurs
– Less CMS & OHFC oversight
– Healthier resident condition
– Fewer legal expenses
– Less stress on resources
– Improved job satisfaction
and retention
– Improved customer relations
– Improved reputation for
quality care
– Less risk management
A Resident Has Fallen
What Do You Do?
(Old system prior to RCA.)
5. Culture Change (driven by
RCA)
RCA transforms a culture that reacts to problems into a
culture that solves problems before they escalate.
Aiming performance improvement operations at root
causes is more effective than merely treating the
symptoms of problems.
Problems are best solved by eliminating and correcting
the root causes, as opposed to merely addressing the
obvious symptoms with scatter-gun approaches to
solutions.
RCA is performed with conclusions and causes and
supported by documented, evidence-based practice.
Tip of the Iceberg
We only see the tip
of what is really there
Keep looking
Keep digging until you find
the real cause(s) of this
particular fall, this
particular incident
TITANIC – Why Did it Sink?
Every System Is Perfectly
Designed to Get the Results It
Achieves
We need to ask,
“Where did the system fail?”
A true story of RCA in action –
or when the system failed.
Hurdles and Challenges
•
RCA competency
– Root Cause Analysis vs. Just Tell Me What To Do
– Scatter gun approach to interventions vs. matching
interventions to root cause of fall
•
Staff resists change
– A tendency to return to the old ways of doing things
•
Sustainability: building systems (redundancy)
– It becomes part of the culture
•
Not just a nursing program any more
– Get everyone on board
•
OSHA Safe Patient Handling vs. reduction in
resident independence = falls
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
provement for people and communities.