Inspiring Excellence in LTCRoot Cause Analysis

Presented by

Craig Erickson and Beth Irtz, Wind Crest

Quality Improvement Is…• The integrated, comprehensive, organization-

wide methodology used to continuously examine, refine, and revise organizational processes to meet and exceed customers’ expectations

• The integration of fundamental management approaches, improvement efforts, tools, and training

• An environment that is supportive of excellence, non-threatening in nature, open to suggestions, and conducive to positive change

Quality Improvement Is…

• The philosophy that employees want to do their best

• Focused on improving systems and processes• Based on measurement, data, and facts• Dependent on teamwork and participation by all• Supported by the facility’s culture, practices, and

shared values

Comparison of QA & QI

Focus Catch “Bad Apples” or Detect Serious Problems

Improve Processes – Not Fault Finding

Goal Meet MinimalStandards

On-going Process Improvement

Who Is Involved

Usually 1-2 individuals in SNF

Teams

Driven By Regulation Accreditation

Organization

When Occurs

Monthly or Quarterly

Continuous

QA QI

Shift to Quality Improvement

• Often times facilities can deliver excellent resident care

• At times may fail to provide excellent services or resident outcomes

• Trying harder will not work• Changing systems of care will work• Need new ideas, tools and systems

Model for Quality Improvement

AssessPerform

ance

InvolveEmploye

es

Evaluate forImprovement

Identify Problem

Quality

Planning&

Prioritization of

ProcessesEducation&

Training

Quality Improvement

Improved Quality Comes From

Improvement in

Work Processes

Achieving Quality

‘The House

of Quality’

Types of Systems

• System of Work: How work is done

• System of Management: How the system of work is managed

Must improve both to be truly effective

Analyze Systems

• Clinical staff works together

• Smooth running front line units

• Information readily available, flows in an easy & timely manner

• High quality, efficient care

• Clinical staff works against each other

• Health care units in tangles

• Poor flow of communication, information fragmented

• Harmful, wasteful and expensive

Improved Quality Comes from Improved Work Processes

• A process is a combination of steps that produce a final result

• Example- pain assessment + administration of analgesics = pain relief

• Only by analyzing & correcting problems with the processes (e.g. no pain assessment) will the desired results be achieved

Goals of Process Improvement

• Identify problem areas• Identify sources of variation• Simplify• Eliminate duplication, unnecessary work• Eliminate rework, extra steps• Remove waits, delays• Decrease potential for errors/mistakes• Eliminate waste/reduce expenses

Change vs. Improvement

• Change does not equal improvement• Change makes something different• Improvement makes something better• “95 % of changes have nothing to do with

improvement” (Peter Scholtes)• Improvement is planned, fundamental

change which results in unprecedented levels of performance

How to Improve Processes:Scientific Method

• Make decisions based on data, rather than hunches

• Look for root causes of problems rather than react to superficial symptoms

• Seek permanent solutions rather than rely on quick fixes

• Plan and make changes, not “ready, fire, aim”

State Desired OutcomesOpportunity Statement

Describe Current SituationIdentify Problems

Collect and Analyze Data

Uncover Root Causes

Generate Solutions

Plan

Pilot Test

Check – Study/Evaluate

Implement

Process Improvement Roadmap

Steps to Quality Improvement Worksheets

Getting Started– Facility Self-Assessment Checklists

• Identifying Areas for Improvement• Forming a Team• Team Meeting Notes

Steps to Quality Improvement Worksheets

Quality Improvement Implementation– PDSA

• Goal Setting• Current Process Analysis• Root Cause Analysis• Fishbone Diagram• Process Improvement Plan• Implementation Strategy• Pilot Testing• Ongoing Monitoring

PDSA CycleWhat is it?• A systematic, scientific method for improving

processes• Closed loop process for continuous quality

improvement• One cycle flows into the next cycle using

information gathered in the previous cycle

When do you use it?• Used to evaluate an entire process or to target

areas within a system once the problematic areas have been identified

PDSA CyclePDSA Cycle• Plan

• Do

• Study

• Act

Plan

Do

Study

Act

PDSA Cycle

• PLAN: Decide to do something differently• DO: Observe what happens• Study: Reflect on what you observed• Act: Continue, Modify or Abandon

Root Cause Analysis

A way of looking at unexpected events and outcomes to determine all of the underlying causes of the event and recommend changes that are likely to improve them.

Requires Critical Thinking

Why Event Investigation is Difficult

• Natural reactions to failure

• Tendency to stop too soon

• False belief in a single reality

• “One Root Cause” Myth

Reacting to Failure

Natural reactions to failure are:• Retrospective—hindsight bias• Proximal—focus on the sharp end• Counterfactual—lay out what people could

have done• Judgmental—determine what people

should have done, the fundamental attribution error

Stopping Too Soon

• Lack training in event investigation– We don’t ask enough questions– Shallow understanding of the causes of

events

• Lack resources and commitment to thorough investigations

False Belief in Single Reality

• People perceive events differently

• Common sense is an illusion– Unique senses– Unique knowledge– Unique conclusions

The “One Root Cause” Myth

• There are multiple causes to accidents

• Root Cause Analysis is not about finding the one root cause

• Best determined by a team rather than an individual or just one department

New View of Human Error

• Human error is not the cause of events, it is a symptom of deeper troubles in the system

• Human error is not the conclusion of an investigation, it is the beginning

• Events are the result of multiple causes

Creating the Holes

Active Failures– Errors and violations (unsafe acts) committed

at the “sharp end” of the system– Have direct and immediate impact on safety,

with potentially harmful effects

Creating the Holes

Latent Conditions– Present in all systems for long periods of time– Increase likelihood of active failures

“Latent conditions are present in all systems. They are an inevitable part of organizational life.”

James Reason “Managing the Risks of Organizational Accidents”

Root Causes

• A root cause is typically a finding related to a process or system that has potential for redesign to reduce risk

• Active failures are rarely root causes

• Latent conditions over which we have control are often root causes

“The point of a human error investigation is to understand why actions and assessments that are now controversial, made sense to people at the time. You have to push on people’s mistakes until they make sense—relentlessly.”

Sidney Dekker

How PDSA Can Help You

• Guides you through steps to increase your chances of success in improving a process

• Leads to ongoing improvement of methods and procedures

Tools of Quality

• Fishbone Diagram

• Top Down Flow Chart

• Checklist

• Control Chart

• Pareto Chart

• Scatter Diagram

Why Use Data to Make Decisions

• Changes are made based on solid information rather than intuition

• Provide objective measurement• Help determine the degree of the problem• Show variation and causes of variation• Help identify root causes of the problem• Help develop appropriate solutions• Baseline for determining whether the changes

really made a difference

Fishbone DiagramWhat is it?• A cause and effect diagram, also known as an Ishikawa or

"fishbone" diagram, • Graphic tool used to explore and display the possible causes of

a certain effect. Use the classic fishbone diagram when causes group naturally under the categories of Materials, Methods, Equipment, Environment, and People. Use a process-type cause and effect diagram to show causes of problems at each step in the process.

• Diagram that is used to display possible causes of specific problems

• Represents the relationship between some “effect” and all possible “causes”

When do you use it?• When you need to identify, explore and display the possible

causes of a specific problem

Fishbone Diagram

• A cause and effect diagram has a variety of benefits:

• It helps teams understand that there are many causes that contribute to an effect.

• It graphically displays the relationship of the causes to the effect and to each other.

• It helps to identify areas for improvement.

Top Down Flow Chart

What is it?• Chart that illustrates relationships between

processes or components within a system

When do you use it?• When you need to understand how a process

works• When you need to identify what different

factors influence a process

Steps to Quality Improvement Worksheets

Quality Improvement Implementation– PDSA

• Goal Setting• Current Process Analysis• Root Cause Analysis• Fishbone Diagram• Process Improvement Plan• Implementation Strategy• Pilot Testing• Ongoing Monitoring

Select Changes

• How will we know that change is an improvement?

• Is the selected change directly related to the problem?

• Is it testable?• Can you measure the result?• Do you expect a significant impact?

Steps to Quality Improvement Worksheets

Quality Improvement Implementation– PDSA

• Goal Setting• Current Process Analysis• Root Cause Analysis• Fishbone Diagram• Process Improvement Plan• Implementation Strategy• Pilot Testing• Ongoing Monitoring

Fishbone Diagram

What is it?• Diagram that is used to display possible

causes of specific problems• Represents the relationship between some

“effect” and all possible “causes”When do you use it?• When you need to identify, explore and

display the possible causes of a specific problem

Implementation and Testing

• Test on a small scale• Use short timeframes• Test until you have confidence in the new

process• Goal is system wide change

Monitoring & Sustaining Improvement

• Incorporate changes into work processes• Identify potential barriers & develop

contingency plans• Monitor periodically• Assign monitor or team leader

Why do RCA?

• To learn the cause(s) of a quality problem

• To make changes in a process related to the causes

• Reduce injury, harm or medical error in the future

Root Cause Analysis at Erickson Retirement

Communities

Hazard/ Contributing cause under Community care, custody and control?

Yes*

* Call AED who will contact Risk Finance and Claims which will provide further guidance, DO NOT proceed with an RCA without authorization from the AED.

Involves three or more departments?

Repetitive Event?

Serious Event? *Serious Incident definitions in GS6060

Triggers for RCA

Steps in Completing a Chronology

Work backward from the reason for investigation through the actions that preceded the reason for investigation. Work forward from the event to identify the post-incident actions.

After the pre-incident and post-incident sequence of events are defined and placed in sequential order, answer the following questions:

•Does the time line of events adequately tell the “story” of the incident? If not the scope of the timeline may need to be extended (pre incident and/ or post incident)

•Is each event derived directly from the event it precedes? If each event is not derived logically from the one preceding it, it usually indicates that one or more steps in the sequences have been left out. Add missing events to the timeline.

•Is each event pertinent to the problem? Answer this question about each event in the time line. The answer may be “yes”, “no” or “not sure.” Include only the “yes” and “not sure” events in the final timeline.

Chronology of Events

Erickson’s Goals Upon Completion of the training the RCA Team will • Understand the responsibilities of the RCA Team• Understand the process for Fast Track RCA• Know the tools and reference material available for RCA• Know when to conduct Fast Track RCA and who should

participate • Have practiced a Fast Track RCA

– Utilized a WC and GL scenario– Utilized tools/reference material

Policy Introduction

“Root Cause” is the factor(s) that started the chain of events that eventually lead up to the unfavorable outcome.

Objective of RCA: through review and discussion, discover where

in the Chain of events, intervention(s), or a different action, if taken, would have prevented or reduced the impact of the final outcome. Then implement these interventions/actions and monitor for effectiveness.

Roles and ResponsibilitiesRCA Team Leaders:• For resident, visitor and property related

events, the SEC/EMS or Facility manager or their delegate will assumed this role.

• For employee related events, the human resources director or delegate will assume this role.

• Upon notification by SEC/EMS that a “serious incident” or HR that a “lost time incident” has occurred, the RCA Team Leader

• Qualifies the need for an RCA • Engages the appropriate members of RCA Team• Initiates & Facilitates RCA process• Documents, communicates with PI/RM/S, and closes

process

Roles and Responsibilities

Root Cause Analysis Team (RCA Team):• Multidisciplinary team of up to ten designated

members, including members from at least.• General Services - Security/EMS• Human Resources• Dining Services• Resident Life

• Conducts an RCA for all “serious incidents” occurring within the community.

• Lead by a RCA Team Leader

Conducting an RCA

• RCA employs a group of methodologies aimed at identifying the underlying , “root” causes of why errors occur.

• RCA should be conducted as a fact finding not a fault finding endeavor with prevention as the primary goal.

Conducting an RCA

STEP 1 → Assemble Team and Fact Finding

STEP 2 → Analyze Data to Determine Cause

STEP 3 → Develop Corrective Actions

STEP 4 → Document the RCA

STEP 5 → Monitoring Corrective Actions for Effectiveness and

Sustainability

• The RCA Team Leader provides a briefing to the RCA Team

– Defines the scope of the Fast Track or Formal RCA.– Establishes deadline for completing the Fast track or Formal

RCA – Assigns duties to each team member

• RCA Form started– A description of the incident – Data gathered for analysis (ongoing process)

WHO - WHEN – WHERE - WHAT

STEP 1 → Assemble Team, Gather Data

Ask why this happened !

● Apply root cause analysis problem solving techniques to the incident to identify contributing factors.

● After review of findings, identify the Root Cause(s)

STEP 2 → Analyze Data

Corrective actions should:• Be specific to address the root cause(s) of the

incident.• Be measurable to assure their effectiveness and

sustainability.• Be achievable from operational and budgetary

view• Be realistic and keeping within Erickson Way

Values.• Be time bound with a rigid corrective action date

based upon the severity and likelihood that the incident will reoccur.

STEP 3 → Develop Corrective Actions

• Utilize the Root Cause Analysis Form to document a Fast Track RCA for incidents involving residents, employees, visitors, and property.

STEP 4 → Document the RCA

Erickson’sRoot Cause Analysis Form

• Who, What, When, Where– Interviews, review of P&P, documents reviewed resources and consultation utilized

• Why root cause analysis process asks why 5 times– Detailed analysis of the facts– Process, equipment, human factors, information,

environment, corporate culture, uncontrollable factors, additional factors and causes

• Development of action plan and additional comments

• The Community Performance Improvement Committee (QA or QI Committee) reviews all RCAs submitted from the previous month.

• The results of the RCA are entered into the Committee minutes.

• Root cause(s)• Corrective action(s) and responsible party• The corrective action date

• Monitor the status of the corrective action(s) to assure their effectiveness and sustainability and reflect in committee minutes.

STEP 5 → Monitoring Corrective Actions

Demonstrated Success using RCA

• Prevent injury of others

• Prevent future harm to a resident who has already been injured

• Prevent serious injury

• Identify neglect

• Identify organizational process problems and assist in development of actions plans

Practice Exercises

• Workers’ Compensation

• General Liability

Conclusion

The RCA Process:

• Determines the incident causes

• Fixes contributing factors that lead to injury

• Reduces the possibility of future incidents

• Protects health and welfare of residents and employees

• Protects Erickson resources