Inspiring Excellence in LTC Root Cause Analysis Presented by Craig Erickson and Beth Irtz, Wind...
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Transcript of Inspiring Excellence in LTC Root Cause Analysis Presented by Craig Erickson and Beth Irtz, Wind...
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
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 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
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.
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