Root Cause Analysis – Assisted Living - WHCA/WiCAL
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Root Cause Analysis – Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS
Transcript of Root Cause Analysis – Assisted Living - WHCA/WiCAL
Root Cause Analysis – Assisted Living
Frieda Pulkowski, RN, BSN, NHA, MS
Definitions
Physical
Human
Organizational
Common Causes
Order within chaos…
Why?
Proactive versus reactive living
Why?
Performance improvement
Clinical versus non clinical indicators
What else…
Why?
Team and roles
Meeting ground rules
Who?
Selection and characteristics of performance measures/incidents and events to analyze
How?
A word about data collection…
Ask the housekeeper AKA “You can’t handle the truth”
How?
The questions to ask
How?
Determining the root cause(s)
Is it controllable and fixable or not
How?
Common “don’ts”
How?
Caution….
Correlation versus
Causation versus
Coincidence
And….what about computers?!
How?
Types of RCA
The 5 Whys
Fishbone/Ishikawa Diagram
Narrative Sequencing of Events
Others
How?
Formatting the FP way
How?
The Examples
Plan and develop – typical approaches are:
Your method
Failure mode and effects
Impact analysis
Kaizen
Others
Next Steps
Implement
Next Steps
Evaluate
Next Steps
Follow up
Next Steps
Causal factor charting
What Else
Q and A
