Root Cause Analysis: Beginning the Investigation. A Practical Application

1. Root Cause Analysis: Beginning the Investigation. A Practical Application Diane Rydrych Assistant Director, Division of Health Policy, Minnesota Department of Health Sue Ann Guildermann Director of Education Empira Betsy Jeppesen Vice President, Program Integrity Stratis Health Linda Shell Corporate Director, Education Volunteers of America

3. 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

4. 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.

5. RCA applied to fall prevention: • Why did the resident fall down? • Why might the resident fall down?

6. 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

7. 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

8. Awareness Test

9. 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

10. 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

11. Observing the scene

12. 10 Questions for RCA of Falls:Directs observation process • 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) • Floor (wet, urine, shiny, carpet, etc.) • Footwear • Assistive devices • Glasses/hearing aids • Who was in the area?

13. Observing the scene

14. Investigate physical environment • Place of fall: • At bedside, 5 feet away, > 15 feet • Orthostatic, balance/gait, strength/endurance • In bathroom/at commode: contents of toilet • Urine or feces in toilet/commode? Urine on floor? • 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?

15. 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

16. Investigate resident condition • Orthostatic B/P, vital signs, PERRL, level of consciousness, bleeding, hand grasp • The 4Ps: pain, position, personal needs, personal items • Last meds? (Diuretic?) Med review needed? • Last eaten? Last voided? Sleep or rest deprived? • Labs: glucose level, Hgb and Hct(anemic), SO2, UA/UC, X-ray, Vit D level

17. Root Cause Analysis Fall Occurs No Yes Care Plan Assessments and/or interventions Employee and/or system failure Alterations from resident’s baseline Alterations in Environment

18. Why interventions sometimes don’t work Because they didn’t address the root causes of the fall.

19. Observing the scene

20. Questions? Sue Ann Guildermann Director of Education Empira 952-259-4477 sguilder@empira.org www.empira.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 Betsy Jeppesen Vice President, Program Integrity Stratis Health 952-853-8510 or 877-787-2847 bjeppesen@stratishealth.org www.stratishealth.org Linda Shell Corporate Director, Education and Learning Volunteers of America 651-503-8885 lshell@voa.org

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