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INTERACT with QAPI

INTERACT with QAPI. Conducting Root Cause Analysis Foundational Track October 30, 2013. Educational Credits for Today’s Webinar. CPHQs – NAHQ approved Nursing Home Administrators - NAB-NCERS approved Nurses – approved nsg . contact hours

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INTERACT with QAPI

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  1. INTERACT with QAPI Conducting Root Cause Analysis Foundational Track October 30, 2013

  2. Educational Credits for Today’s Webinar • CPHQs – NAHQ approved • Nursing Home Administrators - NAB-NCERS approved • Nurses – approved nsg. contact hours • Physicians – AMA PRA Category 1 CreditTM • PTs – WPTA approved • Social Workers – NASW approved • Dietitian – pending from CDR

  3. Attendance Verification for Credits • Full SERIES attendance (four webinars) and • Evaluation: Copy and enter into your web browser: http://www.surveymonkey.com/s/Interact10-30-13 • Social Workers – post-test required (is part of eval) • Everyoneplease complete the online evaluation – thank you!

  4. Disclosures • No commercial support for webinar • Speaker or planner conflicts of interest – None

  5. Learning Objectives Following this webinar, you will be able to: • Identify best practices for the RCA process • Use the Acute Care Transfer Log Tool to determine causative factors that relate to unnecessary re-admissions • Use the Quality Improvement Tool for Review of Acute Care Transfers • Use the Quality Improvement Summary Worksheet

  6. Today’s Presenters • Jody Rothe, RN, WCC • Stephanie Sobczak, MS, MBA • Connie Gliniecki, RN, DON

  7. INTERACT with QAPIRoot Cause Analysis Webinar • Notes for Logging into INTERACT with QAPI Webinar Series: • Please dial into the 1-800 phone line separately from your computer’s webinar login steps. • Please MUTE your computer speakers during the webinar. • Never place your phone on HOLD during the webinar. • Unless you are speaking, please MUTE the phone line by selecting *6. • You can un-MUTE your phone line to speak by selecting *7. • Keep intentional background noise to a minimum during the webinar. • By following these instructions, a better webinar experience will be possible for all participants. • Thank you. INTERACT with QAPI

  8. Collaborating Organizations • And our Expert Advisory Panel: • Barb Beardsley - DON, Brookside Care Center • Connie Gliniecki - DON, Kennedy Park Nursing and Rehab Center • Lisa Gervais - NHA, Pine Crest Nursing Home • Kristen Strother - MSW, Manager of Social Work, Case Management and Abuse Response Services, Aurora Sinai Medical Center INTERACT with QAPI

  9. Today’s Agenda Sharing from Connie Best Practice Processes for Conducting a Root Cause Analysis (RCA) AE Safely Reduce Hospitalization Tool The QI Tool for Review of Transfers QI Summary Worksheet Suggested Action Steps INTERACT with QAPI

  10. INTERACT with QAPI

  11. From the Expert Connie Gliniecki - DON, Kennedy Park Nursing and Rehab Center • The importance of doing an RCA • What works well and what doesn’t • Learning from the process • Part of QAPI • Should be completed by any staff at the time of an identified problem INTERACT with QAPI

  12. From the Beginning… • Do you have a consistent process for conducting RCAs? • Are the same people leading or instructing others in the RCA? • How are the caregivers involved with the patient included in the RCA? INTERACT with QAPI

  13. Best Practices for RCA Involve those who worked with the resident– interview them Follow the Tool and assess all the questions Meet to compare findings and determine what the cases have in common If there is not a clear root cause, use the 5 Why Approach INTERACT with QAPI

  14. Best Practices for RCA Involve those who worked with the patient – interview them Follow the Tool and assess all the questions Meet to compare findings and determine what the cases have in common If there is not a clear root cause, use the 5 Why Approach INTERACT with QAPI

  15. Best Practices for RCA Involve those who worked with the patient – interview them Follow the Tool and assess all the questions Meet to compare findings and determine what the cases have in common If there is not clear root cause, use the 5 Why Approach INTERACT with QAPI

  16. INTERACT QI Tool INTERACT with QAPI

  17. INTERACT QI Tool Which of these are most common? Helps you determine which processes might be improved or refined. INTERACT with QAPI

  18. INTERACT QI Tool Example INTERACT with QAPI

  19. Introducing the Tool to Staff First have at least one experienced staff person review tool and try RCA with one case. To continue; • Option 1- Introduce the RCA with one staff person at a time and ask them to fill out the QI tool • Option 2- Introduce the RCA to the team and ask them to Interviewpeople involved with a recent readmission INTERACT with QAPI

  20. Best Practices for RCA Involve those who worked with the patient – interview them Follow the Tool and assess all the questions Meet to compare findings and determine what the cases have in common If there is not clear root cause, use the 5 Why Approach INTERACT with QAPI

  21. INTERACT QI Summary Worksheet INTERACT with QAPI

  22. INTERACT QI Summary Worksheet INTERACT with QAPI

  23. Best Practices for RCA Involve those who worked with the patient – interview them Follow the Tool and assess all the questions Meet to compare findings and determine what the cases have in common If there is no clear root cause, use the 5 Why Approach INTERACT with QAPI

  24. The 5 Why Approach Case Example: Two patients were sent to the hospital in the past 2 weeks because of decreased fluid intake or very low urinary output. In both cases the physician determined patients were dehydrated, and after giving fluids, each was able to return to the facility. INTERACT with QAPI

  25. The 5 Why Approach Mrs. Adams’ dehydration: She was refusing to drink water Why? She will only drink bottled water Why? Her daughters tell her bottled water is better for her and bring her a supply of bottled water.  She was out of bottled water, so we need to supply bottled water. INTERACT with QAPI

  26. The 5 Why Approach Mr. Brown’s dehydration: No history of swallowing difficulties but was dehydrated Why? Patient had mentioned a sore throat Why? Patient had an endoscopy 3 days ago and hasn’t been drinking water at bedside or meals.  Throat pain caused by procedure that staff were not aware of; were unaware of degree of discomfort for the patient. INTERACT with QAPI

  27. The 5 Why Approach Mr. Brown’s dehydration: Throat pain caused by procedure that staff were not aware of; were unaware of degree of discomfort for the patient. Why was staff unaware of the procedure? The physician’s note and follow-up instructions were not received. Why?  No standard process with clinics for information/follow-up after appointments. INTERACT with QAPI

  28. Commonly Discovered Root Causes Communication breakdowns: Missed signs of resident condition changes Staff respond to clinical situations differently Handoff problems with other organizations INTERACT Tools not consistently used INTERACT with QAPI

  29. Prioritizing Findings Come to a group consensus on the top 2 or 3 things that could be improved based on your Root Cause Analysis Update your QAPI Goal Setting Worksheet INTERACT with QAPI

  30. QAPI Use QAPI Toolkit for your performance improvement plan Revisit your Goal Setting Worksheet to update your plan based on your finding from the Root Cause Analysis INTERACT with QAPI

  31. How INTERACT Links to Root Causes Communication breakdowns  SBAR Missed signs of resident condition changes  Stop and Watch Tool Staff respond to clinical situations differently  Care Pathways Handoff problems with other organizations  Transfer Tools INTERACT with QAPI

  32. Make a Plan to Do the Improvements What will you do for action steps? Who will do the work? Who should be involved? When should steps be completed by? How will you make progress? How will you know progress is on track? What? Who? When? How? INTERACT with QAPI

  33. “How is it Going” Checklist • Are you meeting as a team? • Is data being gathered and submitted in a timely way? • Have you agreed upon clear next steps • Have you connected with other staff to participate in the effort? • Are you updating your QAPI Goals Worksheet? INTERACT with QAPI

  34. Recommended Action Items INTERACT with QAPI

  35. Online Resources Recorded Webinars available on: Wisconsin Clinical Resource Center https://wcrc.chsra.wisc.edu(Requires your WCRC Username and Password) WHA Quality Center http://www.whaqualitycenter.org/LearningOpportunities/INTERACTwithQAPI.aspx Other resources: INTERACT Website http://interact2.net/ MetaStar QAPI Resources http://www.metastar.com/web/Default.aspx?tabid=573 Advancing Excellence – Safely Reduce Hospitalizations Tracking Tool (Data spreadsheet) http://www.nhqualitycampaign.org/star_index.aspx?controls=hospitalizationsidentifybaseline INTERACT with QAPI

  36. References INTERACT with QAPI

  37. Attendance Verification for Credits • Full SERIES attendance (four webinars) and • Evaluation: Copy and enter into your web browser: http://www.surveymonkey.com/s/Interact10-30-13 • Social Workers – post-test required (is part of eval) • Everyoneplease complete the online evaluation – thank you!

  38. Jody Rothe, RN, WCC Quality Consultant MetaStar, Inc. 2909 Landmark Place Madison, WI 53713 Phone number: (608) 441-8271 or (800) 362-2320 www.metastar.com jrothe@metastar.com Contact Information: INTERACT with QAPI

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