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  Physicians – AMA PRA Category 1 Credit TM  PTs – WPTA approved  Social Workers – NASW approved  Dietitian – pending from CDR

Attendance Verification for Credits  Full SERIES attendance (four webinars) and  Evaluation: Copy and enter into your web browser: 13  Social Workers – post-test required (is part of eval)  Everyone please complete the online evaluation – thank you!

Disclosures  No commercial support for webinar  Speaker or planner conflicts of interest – None

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

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

INTERACT with QAPI Root Cause Analysis Webinar INTERACT with QAPI 7 Notes for Logging into INTERACT with QAPI Webinar Series:  Please dial into the 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.

Collaborating Organizations INTERACT with QAPI 8 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

Today’s Agenda 1.Sharing from Connie 2.Best Practice Processes for Conducting a Root Cause Analysis (RCA) 3.AE Safely Reduce Hospitalization Tool 4.The QI Tool for Review of Transfers 5.QI Summary Worksheet 6.Suggested Action Steps INTERACT with QAPI 9

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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 11

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 12

Best Practices for RCA 1.Involve those who worked with the resident– interview them 2.Follow the Tool and assess all the questions 3.Meet to compare findings and determine what the cases have in common 4.If there is not a clear root cause, use the 5 Why Approach INTERACT with QAPI 13

Best Practices for RCA 1.Involve those who worked with the patient – interview them 2.Follow the Tool and assess all the questions 3.Meet to compare findings and determine what the cases have in common 4.If there is not a clear root cause, use the 5 Why Approach INTERACT with QAPI 14

Best Practices for RCA 1.Involve those who worked with the patient – interview them 2.Follow the Tool and assess all the questions 3.Meet to compare findings and determine what the cases have in common 4.If there is not clear root cause, use the 5 Why Approach INTERACT with QAPI 15

INTERACT QI Tool INTERACT with QAPI 16

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

INTERACT QI Tool Example INTERACT with QAPI 18

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 Interview people involved with a recent readmission INTERACT with QAPI 19

Best Practices for RCA 1.Involve those who worked with the patient – interview them 2.Follow the Tool and assess all the questions 3.Meet to compare findings and determine what the cases have in common 4.If there is not clear root cause, use the 5 Why Approach INTERACT with QAPI 20

INTERACT QI Summary Worksheet INTERACT with QAPI 21

INTERACT QI Summary Worksheet INTERACT with QAPI 22

Best Practices for RCA 1.Involve those who worked with the patient – interview them 2.Follow the Tool and assess all the questions 3.Meet to compare findings and determine what the cases have in common 4.If there is no clear root cause, use the 5 Why Approach INTERACT with QAPI 23

The 5 Why Approach INTERACT with QAPI 24 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.

The 5 Why Approach INTERACT with QAPI 25 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.

The 5 Why Approach INTERACT with QAPI 26 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.

The 5 Why Approach INTERACT with QAPI 27 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.

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 28

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 29

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 30

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 31 How INTERACT Links to Root Causes

What? Who? When? How? 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?

“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 33

Recommended Action Items INTERACT with QAPI 34 Root Cause Analysis Action Items 1. Determine who is involved in tracking transfers; check on data submission 2. Review 3-5 Acute Care Transfers with the team; use QI Tool and determine root causes 3. Modify your QAPI Goal Setting Worksheet (your PIP) and develop a plan 4. Submit data

Online Resources INTERACT with QAPI 35 Recorded Webinars available on: Wisconsin Clinical Resource Center (Requires your WCRC Username and Password) WHA Quality Center Other resources: INTERACT Website MetaStar QAPI Resources Advancing Excellence – Safely Reduce Hospitalizations Tracking Tool (Data spreadsheet)

References INTERACT with QAPI 36

Attendance Verification for Credits  Full SERIES attendance (four webinars) and  Evaluation: Copy and enter into your web browser: 13  Social Workers – post-test required (is part of eval)  Everyone please complete the online evaluation – thank you!

Contact Information: INTERACT with QAPI 38 Jody Rothe, RN, WCC Quality Consultant MetaStar, Inc Landmark Place Madison, WI Phone number: (608) or (800)