Root Cause Analysis

Prepared for Alabama
“Accident Investigation:
Root Cause Analysis”
Patricia J. Boyer, MSM, RN, NHA

President/Operations Consultant
Boyer & Associates, LLC

16655 W. Bluemound Rd. Ste. 170
Brookfield, WI 53005
Ph.: 262-754-0525 Fax: 262-754-0528
What is Root Cause

Analysis?
• Root Cause Analysis is a method that

is used to address a problem or non-
conformance in order to get to the
conformance,
“root cause” of the problem. It is
used so we can correct or eliminate
the cause, and prevent the problem
from recurring
Adapted from NASA Root Cause

Analysis
What is Root Cause?

• Root Cause is the fundamental
breakdown or failure of a process which,
when resolved, prevents a recurrence of
the problem.
Or,, in other words
• Root Cause is the factor that, when you
fix it, the problem goes away and doesn’t
come back.
• Root Cause Analysis is a systematic
approach to get to the true root causes of
our process problems.

Analysis
1
Philosophy of Root Cause

Analysis
• Each problem is an opportunity because it
can tell a story about why and how it
occurred.
• It is critical that everyone take a personal
and active role in improving quality.
• The “true” problem must be understood
before action is taken.
• To do this well, you must be
– Both focused and open-minded
– Both patient and quick
Analysis
Symptom Approach vs
Root Cause
• Symptom Approach • Root Cause
– Errors are a – Errors are a
result of worker result of process
carelessness failure. People
– Trainingg to are only part of
motivate people th
the process
to be more – Find out why it
careful happened &
– Don’t get to the implement
bottom of the processes so it
problem won’t happen
again
– Fix it for good
Analysis
How do we do Root Cause

Analysis?
• Ask the Why
–Why did the problem occur?
–They ask why that happened
until
til you reach
h the
th process
element that failed.

Analysis
2
Types of Tools Used in Root

Cause Analysis
• Brainstorming
• Fishbone Diagram
• Flowchart
3
Applying the Nursing

Process-The biggest
“clue”
clue of success
Nursing Process/System
Process
Reevaluate
Performance
Assessment
Monitor and Modify Identify Recognition of

Audit & Monitor Risk Factors
Identify the
Reinforce Optimal
Performance Implement Evaluate Cause
Develop Action Plan

Implement Necessary
Changes
Measuring/Evaluation
of Facility Standards of
Clinical Practice
4
Evidence Based
• What is “Evidence-Based Practice”
The use of current best evidence in
making decisions about the care of
individual residents.
• What is “Evidence-Based Facility
Practice”
The integration of the clinician’s
expertise with values, resident
preferences and available evidence.
Sackett, Gray, Haynes & Richardson, 1996
Standardized Approach
• Use an organized approach
• Emphasize the basic process:

prevention,
ti assessment,
t
documentation and treatment
“One of the tests

of leadership
is the ability to recognize
a problem
before it becomes
an emergency.”
Arnold Glasgow
5
Status Reviews
Review Systems:
• Flow chart/graph/data collect
processes
• Review and tweak
policy/procedures as you go-not
as overwhelming
• Review compliance with practice
standards
• Audit-at minimum 10% monthly
Strategies for Facility

Improvement: Evaluate
Risk Factors
• Target Resident and interview
• Family interviews
• Resident Satisfaction Surveys
• Staff Satisfaction Surveys
• Interview Staff for
Suggestions/changes/improvem
ents
Assessments
Admission, Quarterly, Significant
Change minimally include:
• Fall Risk
• Smoking ability
• Elopement
El t risk
i k
• Pain assessment
• Behavioral assessment
• Skin assessment
• Bowel, bladder assessment
• Quality of Life- Restorative
6
Facility Action Steps
Develop a plan
• Seek guidance
Regulatory language
–Regulatory
–Medical Director and Physicians
–Employees
–Peers
–Professional organizations
–Consultants

Implementation
• Set goal date
• Develop an Action plan
• Monitor progress frequently
• Educate staff
• Implement the plan

Evaluate
• Has the goal been met?
• Are there any adjustments
needed?
–Seek input from residents,
family and staff
•Make adjustments and/or
redefine the plan
7
Monitor
• Set up a routine timeframe
• Assign responsibilities
• Enforce accountability
• Re-evaluate systems regularly
“If you don’t know

where you are going, you
will probably end up
someplace else.”
Someplace Else
Pop. 215 Yogi Berra
Accidents +
Incidents
8
Regulatory Language
Accidents and Supervision F323
The facility must ensure that:
–The resident environment

remains
i as free
f off accident
id t
hazards as is possible; and
–Each resident receives
adequate supervision and
assistance devices to prevent
avoidable accidents.
Methods to Meet Intent
• Identifying hazards and risks;

• Evaluating and analyzing hazards
and
d risks;
i k
• Implementing interventions to
reduce hazards and risks; and
• Monitoring for effectiveness and
modifying interventions as
indicated.
Overview: Commitment
to Safety
A facility with a commitment to
safety:
–Identifies risk
–Reports
R t risk
i k
–Involves all staff
–Utilizes resources
–Commitment to safety
demonstrated at all levels of
organization
9
A Systems Approach
Identification of Hazards and
Risks
Sources for identifying hazards
may include:
Quality assurance activities
–Environmental rounds
–MDS/RAPS data
–Medical history and physical
exam
–Individual observation
A Systems Approach
Evaluation and Analysis
• The facility examines data
gathered through identification
of hazards and risks and applies
it to the development of
interventions to reduce the
potential for accidents.
• Interdisciplinary involvement is a
critical component of this
process.
A Systems Approach
Implementation of
Interventions
• Communicating the interventions
to all relevant staff
• Assigning responsibility
esponsibilit
• Providing training as needed
• Implementing and documenting
interventions
• Ensuring that interventions are
implemented
10
Systems Approach of
Monitoring and Modification
• Ensuring that interventions are
implemented correctly and
consistently
• Evaluating
E l i the
h effectiveness
ff i off
interventions
• Modifying or replacing
interventions as needed
• Evaluating the effectiveness of
new interventions
Resident to Resident
Altercations
Situations that may increase the
potential for resident to resident
altercations include:
• History of aggressive behavior
• Negative interactions with other
residents
• Disruptive or annoying behavior
• History of inappropriate behavior
Supervision Resident-to-
Resident Altercations
• Facilities need to take reasonable
precautions to prevent resident-to-
resident altercations.
• C
Certain
t i situations
it ti or conditions
diti may
increase potential for resident-to-
resident altercations:
– History of aggressive behavior

– Negative interactions with another
resident
– Disruptive or annoying behavior
33
11
Definition:
Supervision/Adequate
Supervision
 “Supervision/Adequate Supervision”
refers to an intervention and means of
mitigating the risk of an accident.
 Adequate supervision is defined by the

type and frequency of supervision,
based on the individual resident’s
assessed needs and identified hazards
in the resident environment.
Prevention of Falls
• Teamwork
• Systems Approach
• Patient specific causes
• Seating and Positioning
• Falls and Medications
12
Cost of Falls
• 5.3% of hospital admissions of
individuals over 65 are due to
falls
• Mean LOS 8-15
8 15 days
• 42% of fallers reduce activity
after falling
• 40-73% of fallers have “fear of
falling”
Good News
• Falls can be successfully
managed
• Must develop a passionate focus
• Understand and use your QIQI’s
s
–QI’s provide a “Sneak Peek at
the Test before the surveyors
get there”
• Trend your falls
• Develop comprehensive team
approach
Bad News - If they’re not

well managed
• Facility
–Fines
–Loss of reputation
–Loss of revenue
–Increased cost of care
–Potential for lawsuits
• Patient
– Fear of ambulating, falling
again
13
Response to Falls
• Immediate response
–Assess patient
–Identify cause of fall
–Medical care for resident
–Establish temporary “keep
safe” plan
–Document intervention
–Complete incident report
How to do it well
• Ideal Outcome
–Maintain the health of the
patient
–Maintain
M i t i theth health
h lth off the
th
facility’s systems
Overview: Commitment
to Safety
A facility with a commitment to
safety:
–Identifies risk
–Reports risk
–Involves all staff
–Utilizes resources
–Commitment to safety
demonstrated at all levels of
organization
14
Systems
Consistent Team Approach
Vigilance Leadership
Systems Review Committed Physicians

No
Trending Citations Assessment System
QIs Immediate Intervention
Good Documentation
Accountability
Interventions - POC
Systems that work -

Teams
• A team is only as good as its weakest
link
• The keys to creating an effective team
are:
– Mutual respect
– Communication
– Focus and passion toward
prevention
– A genuine concern for the safety of
all residents.
15
Teams
• Administrator’s role:
–Sets the expectations
–Sets Environmental standards
–Establishes
Establishes accountability
–Responsible for Regulatory
Compliance and quality of life
for the residents
–Financing - Equipment,
Maintenance, Staff
–Facilitates consistent CQI
Teams
• DON - Coordinates team’s efforts
– Establishes standards and
accountability
– Establishes system for Falls
M
Management t
– Trends incidents and establishes
patterns
– Coordinates team efforts to assess
system failures resulting in
identified trends
– Holds staff accountable
Teams
• Unit Manager = clinical case manager
– Understands all aspects of the
individual patient’s needs, habits
and deficits
– Identifies patient specific risks and
contributing factors
– Is responsible for the quality of her
unit’s focus on falls prevention
– Monitors potential Medical and
Polypharmacy risks for her patients
16
Teams
• Managing Physician
– Often not included -
• Due to lack of time, respect, or
responsiveness
• Nursing tries to solve all problems
in-house without involving the MD
– Must have comprehensive
understanding of Geriatric Medicine
– Must strongly support intervention
to prevent functional loss and
maintain quality of life for the
resident
Teams
• Medical Director
–Responsible for the quality of
Medical Care available in the
building
–Intervenes as an advocate for
the facility when managing
physicians need mentoring
–Takes an aggressive approach
to Quality Assurance
Teams
• Medical Director
– Reviews incidents and accident
trends
– Assists the DON in identifying
system
sys e widede o
or pa
patient
e spec
specific
c
causes
– Assists in modification of policies
and procedures resulting from QA
process
– Communicates with and holds
managing physicians accountable
for following facility policies
17
Teams
• Physical Therapist
– Triages patients into appropriate
activity or restorative programs
through quarterly screens and
evaluations as needed
– Assists the team to identify system
wide and patient specific causes for
falls
– Evaluates specific patients for
balance, coordination, strength and
perceptual deficits
– Provides rehab treatment as
appropriate
Teams
• Occupational Therapist
falls
– Evaluates specific patients for safety
judgment, problem solving and
perceptual skill deficits as they
pertain to late loss ADLs
– Evaluates and modifies seating and
positioning systems to meet needs of
patients
appropriate
Teams
• Speech and Language Pathologists
falls
– Evaluates specific patients for safety
judgment, problem solving, cognitive
and communication deficits as they
pertain to falls
– Consults and provides remedial
equipment for audiological needs of
the patient
appropriate
18
Teams
• Activity Directors and Staff
falls
– Assists with assessment of social,
emotional and physical deficits as
they relate to falls
– Assists the resident to maintain
feeling of self worth through
appropriate activities
– Are key to assisting the resident to
maintain their optimal level of
physical fitness
Teams
• Nursing Assistants
falls
– Are key
y to accurate information
regarding environmental,
behavioral and physical risks to the
safety of residents
– Ensure safety of the resident
through vigilance, common sense
and a strong commitment to the
well being of the resident
Teams
• Maintenance and Housekeeping
falls
– Are key to the environmental safety
of the residents
– Provide prompt repair of brakes on
beds, wheelchairs and other
equipment used by patient
– Prevent clutter and other
environmental hazards that imperil
safety of staff/residents
19
Accountability
• Accountability
–Without accountability, all
plans and interventions are
useless
–Each team member must
understand what they are
accountable to do
–Each manager must hold each
team member accountable for
results, not just process
Team review
• Next morning stand-up meeting
review
• Review contributing factors
• Plan
Pl should
h ld address
dd each
h factor
f t
• Modify intervention if needed
• Document changes in
POC/nurses notes
• Refer to PT, OT, ST if appropriate
Team Review
• Each week - Falls Committee
– All falls are reviewed in-depth
• Causes
• Interventions
• Effectiveness
• Modifications if needed
– All modifications are recorded on
the POC
– Minutes of the meeting are kept
20
Team Review
• Each month Quality Assurance
Committee
–Trends are examined to identify
any patterns
–Systems are reviewed for
potential modification
–Individual patient issues are
reviewed if unresolved
Trends help identify

cause
• If most falls occur during change
of shift
• If most falls occur between 5pm
and 7pm
• If most falls occur on one
particular unit during the
midnight shift and only when
nurse Jane is working
• If most falls occur during the
first 48 hours of admission
Analyzing Information
Garbage in
equals
garbage out
21
Outcomes Analysis
• Requires accurate data collection,
analysis and trending
• Analysis of trends results in
y
identification of system failures
• An acceptable standard must be
identified
• Outcomes compared to that standard
• Progress toward team goals needs to
be communicated to entire team (NAs
too!)
Prevention
• Predict greatest risk
– Shifts
– Units
– New or lower quality staff
• Dedication of staff
– Attitude shift - “It’s a job” to “I’m fond of
my residents”
– Stabilize staffing pattern - Know habits of
residents
Prevention - Staffing
• Staffing Pattern
– Match staffing pattern to identified trends
• Volunteer role
• Family member’s role
• Dual Hats - Multiple roles of all staff
– Sundowner’s hours
– Group patients to allow lower ratio
staff:patient
22
DON or Unit Manager

• Notify physician
• Notify family
• Review incident report and
documentation
• Follow-up intervention plan
– Is equipment in place?
– Have Nurses aides been informed?
– Is staff implementing plan?
– Is plan working?
Follow up by Therapy
• Equipment reviewed
– If equipment must be ordered,
Therapy must also implement a
temporary
te po a y keep
eep safe
sa e plan
pa
equipment arrives
– Therapy must document “keep safe
plan”, and equipment that has been
ordered, expected arrival date
– Therapy to track equipment order
and document in medical chart
Physical Fitness
• Inactivity -
– Loss of balance
– Loss of
endurance
– Loss of postural
reflexes
– Loss of strength
– Loss of speed of
reaction
– Loss of
coordination
– Loss of
confidence
23
Physical Fitness
• Strong Activity program
– Triage all patients into activity
categories
– Walking for distance (walkie talkie)
• Walk across America or your state
– Walk to dine, walk to toilet, walk to
shower
– Transfer to dining room chairs (six
additional sit to stand
opportunities to strengthen
muscles)
Success
• Decrease in incidence of falls
• Improvement in resident safety
• Decreased risk of citations
• Improved customer satisfaction
Washington State Dept of

Health Root Cause Analysis
• The Adverse Event Occurs
Your Policy Explains:
 How to report an event
 How to care for the patient
q p
 How to secure equipment or articles
 How to secure original documents
 When to obtain photos
 Responsibility for Disclosure & Notifications—
Attending MD’s, Client/Patient, Internal & External
Notifications
 How to conduct staff discussions
24
Root Cause Analysis

• Root Cause Analysis
– Step 1 Identify the Adverse Event
– Step 2 Identify the RCA Team
– Step 3 Conduct the RCA
– Step 4 Develop an Action Plan
– Step 5 Measure the Effectiveness of
Plan
– Step 6 Communicate the Findings
Root Cause Analysis

• Step 1 Identify the Adverse Event
– Receive the Adverse Event Report
– Triage the Adverse Event Using Experts
VA National Center for Patient
Safety—Safety
Sa ety Sa ety Assessment
ssess e t Code
Joint Commission Sentinel Events
American Medical Director Association
(AMDA)
Determine Events Not Eligible for
RCA’s
– Receive Organizational Endorsement
Root Cause Analysis

• Step 2 Identify the RCA Team
– Identify Content Experts—Those most
familiar with situation
– Interdisciplinary-Physicians,
Interdisciplinary-Physicians
Pharmacy, Operations
– This is an opportunity to teach staff
how to utilize an RCA methodology
25
Root Cause Analysis

• Step 3 Conduct the RCA
– Short Inservice on Conducting RCA’s
(15 minutes)
– Establish
E t bli h C
Confidentiality
fid ti lit
– Ground Rules for Team Management
– Assign Tasks
Root Cause Analysis

• Step 3 Conduct the RCA
– Meeting 1: Present the Event, Flow Chart
or Time Sequence the Events Known,
Assign Tasks to Members
– Meeting 2: Review Findings from Tasks,
Edit the Flow Chart or Time Sequence,
Identify Causal Statements, and Develop
an Action Plan
– Meeting 3: Establish Effectiveness
Measures and Communication Plan
Root Cause Analysis

• Step 4 Develop an Action Plan
– Literature Review
– Review Findings From: Policy & Procedures,
Interviews, Site Visits, Equipment
Investigations,
Investigations
– Determine Contributing Factors and Root
Causes
– Formulate Causal Statements
– Identify System Changes with Prevention
Plan
– Assign Responsibilities
26
Root Cause Analysis

• Step 5 Measure the Effectiveness of Plan
– How will you know success when you
see it?
– Develop strategy for culture change
– Strategy must impact the root cause
– Education, policy & procedure changes
least effective
– Plan concurrent reviews to determine
effectiveness
Root Cause Analysis

• Step 6 Communicate the Findings
– Plan For Staff Feedback
– Patient Safety Walkrounds
– Newsletters
– Develop a “Press Release”
Compliance Rounds
• Routine environmental rounds
–Water Temps, call-lights, room
management, infection control,
bed device management etc.
etc
• Preventative Maintenance
• Proper drug storage
–Medication Pass
–Medication Rooms
27
Guardian Angel Program

Use of Clinical Round Auditors:
• Advocacy for facility resident (s)
• Regularly randomized reviews
• Selection of a cross spectrum of
key staff from all disciplines
• Documented process for QA/QI
• Performance Improvement
through all staff trained
Other Resources
28
Advancing Excellence
How to get involved:
• Facilities are encouraged to join

the campaign and can sign up for
at:
www.nhqualitycampaign.org
• Quality Materials are available on

the Web: www.MedQIC.org
• State QIOs also can provide facility

support. All QIOs names, addresses
and other contract information are
listed on the MedQIC Web site.
• CMS access to data is through Nursing

Home Compare as previously
available along with aggregate data
results posted to the campaign on a
quarterly basis.
Campaign Eight Goals:
• Reduce Pressure Ulcers
• Reduce Restraint Use
• Improve Pain Management
• Set STAR Targets
• Conduct Satisfaction Surveys
• Improve Retention of Staff
• Increase/use Consistent
Assignments
29
Best Practice Examples

That ARE Practical:
• AT Risk Clinical Meeting
• Photographic Evidence
• Monitoring of Hazards through
Compliance Rounds
• Use of Refusal of Treatment
• Abuse Prevention
• Focus on Resident
• Auditing Documents
• Always BE READY
• Build and Maintain The BEST TEAM
Patient At RISK (PAR)

Clinical Meetings
“Best Practice”
Interdisciplinary team meeting once
per week to identify at-risk residents:
WHO: NHA, DON, RD, Rehab, Pharmacy, Medical Director,

Social Worker,
Worker Activity Director,
Director Hospice
What: At risk issues that have occurred over the course of

past week:
falls, investigations, new behaviors, new open areas,
weight changes, restraint/devices in use, and end of life
changes etc.
Why: Communication of events, interventions put in place,

evaluation of significant change of condition, and care plan
changes made
. What measures will be put into place

or systemic changes made to ensure
that the deficient practice will not
occur.
 Random audits will be completed weekly by
the unit manager to ensure that…..Any
concerns identified will have immediate
corrective action and will be forwarded to
th DON and
the d CQI/PI CCommittee
itt ffor ffurther
th
resolution.
 The policy and procedure has been revised
to ensure that……
 The DON or designee will review 10% of the
records weekly. Any issues identified will
have immediate follow up for corrective
action. All results will be forwarded to the
CQI/PI Committee.
30
A Systems Approach
Monitor and Modify Identify
Implement Evaluate
Lastly Create a Culture

Demonstrating The “Home”
We’d All Want to Live and
Work In
• Focus on effective systems
• Teamwork to accomplish the mutual
goals
• Create a culture of high quality
performance
• Make the facility the type of home
your residents want to live in.
31

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Root Cause Analysis

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Prepared for Alabama

Patricia J. Boyer, MSM, RN, NHA

Boyer & Associates, LLC

What is Root Cause