Root Cause Analysis:
The Process
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
Why do you think this resident
falls down in about 35 minutes?
Clue #1:
What are we going to cover?
• Considerations for conducting a Root
Cause Analysis (RCA)
• Steps in the RCA process
When RCA could be considered
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Events with serious outcome for resident
Repeating incidents
Near misses/good catches
Examples:
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Falls
Medication errors
Pressure ulcers
Plan of care not followed
When the information has been
gathered…
Two approaches to RCA
1) 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.
2) 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
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
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
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
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.
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
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
Ground Rules
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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?
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.”
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
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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
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
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.
Clue #4