1. Root Cause Analysis: Beginning the Investigation
Root Cause Analysis: Beginning the Investigation. A Practical Application
Sue Ann Guildermann
Director of Education
Empira
Betsy Jeppesen
Vice President, Program Integrity Stratis Health
Diane Rydrych
Assistant Director, Division of Health
Policy, Minnesota Department of 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: Falls Depression & Anxiety ADLs 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
This probably needs to be reworded – this slide is off the top of my head this a.m.

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
Sue Ann – does it make sense to have this slide here, or should it be later? I was thinking they’d go through the first picture, then you’d talk about this, then they’d do the second picture as a large group. Does that make sense?
Note: Not sure if we need to reword anything on this slide, so there’s no confusion about ‘systemic causes’ versus the ‘system factors’ that we’ll be talking about elsewhere. Some are the same (policies, staffing, etc), but some are a bit different.

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?
Not sure if this slide is in the right place…..

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
Do we want to add anything about change in status, or whether something has happened in the person’s life that might have contributed to the event?

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 Diane Rydrych Assistant Director Division of Health Policy Minnesota Department of Health
Betsy Jeppesen Vice President, Program Integrity Stratis Health or Linda Shell Corporate Director, Education and Learning Volunteers of America

21. Protecting, maintaining and improving the health of all Minnesotans.
Stratis Health is a nonprofit organization that leads collaboration and
innovation in health care quality and safety, and serves as a trusted
expert in facilitating improvement for people and communities.