2012 User Group. 22 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Harness the Power of...

2012 User Group2012 User Group

22

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


Harness the Power of Root Cause Analysis

June 19, 20122:30-3:45

Joyce Rutherford Donner

33

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


Teaching Root Cause

• Critical Thinking Skills

• Natural Talent

• Long, Hard Slog

44

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


55

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


Important First Step

Investigation Phase:Investigation Phase:

Researching, Asking QuestionsResearching, Asking QuestionsRe-enactmentRe-enactment

66

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


Results of a Good Investigation Include Thoughts About:

• Systems breakdown• Training needs• Resident needs• Environmental needs

77

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


What is the Root Cause?

• Root Cause - a specific underlying reason› Can be reasonably identified› Management has control to fix, change, or care plan› Facilitates development of actions for prevention

• The process of choosing a Root Cause › Will identify “Causal Factors,” contributors that, if

eliminated, would have prevented and/or reduced the severity the occurrence.

› Is not a 1-person job.

88

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


99

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


MethodsMethods

1010

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


Ishikawa (Fishbone) Diagram

1111

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


Cause and Effect Diagram www.skymark.com/resources/tools/cause.asp

1212

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


WHY??

1313

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


Fall from W/C

Trying to get into bed by himself

Staff didn’t find out if he wanted to go to bed

Aphasic and doesn’t have communication board

Res. can’t communi-cate

Confusion d/t low O2 sat

No oxygen therapy

Physician has not ordered

Alarm did not sound

Battery dead

No maintenance program

No data re: O2 sats

No SLP orders

1414

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


Asking “WHY” Without Completing The Investigation Can Lead To Dead Ends

• Resident fell› Why

• Because she tried to stand up without assistance› Why

• I don’t know › Why don’t you know?› I didn’t ask her or the staff

1515

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


Practice

• Using one report so all are working on the same problem› Groups of 3-4› Flip chart paper and markers OR post-it notes› Space to meet as a group

• Create a cause and effect diagram

1616

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


Trainer’s Role During Practice Session

• Assist with the “why” process to prevent jumping to conclusions› Logical conclusion and not what the first

impression was› Desire for a particular reason because a good

intervention is already at hand› Slow down a natural desire to “do it and get it

over with”

1717

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


Trainer’s Role During Practice

• Guide without providing all the answers› You found that the O2 sats were low. So why

were they low? Resident has COPD and no oxygen therapy.

› Resident didn’t have oxygen therapy--WHY? Because the doctor hasn’t ordered.

› The doctor hasn’t ordered– WHY? Because nursing hasn’t presented the O2 sat information.

Natasha Fay Habib

sat?

1818

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


Trainer’s Role During Practice

• Encourage those who are having a hard time› Walk them through each WHY and praise the

smallest of achievements› Offer hints of what they might want to think

about

1919

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions



• Make sure they all do more than one cause and effect for the report› Practice is necessary to imprint on the brain› Many take the examples with them to guide later

attempts

2020

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions



• Identify those with natural ability and get them in a leadership role on the Investigation/Root Cause team

2121

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


Practice Trip-Ups

• If the answers to the questions uncovered in the investigation are not complete, cause and effect will not be able to proceed› Help staff see what they need to know before

they can start, or what they should go back to collect

2222

| 04

/18/

23 |

©

eH

ealth

Dat

a S

olut

ions


Final Step

• Meet as a large group• Each group presents• Others provide feedback with trainer’s guidance• Trainer assesses need for more instruction

2012 User Group. 22 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Harness the Power of...

Documents

Transcript of 2012 User Group. 22 | 4/29/2015 | © eHealth Data Solutions 2012 User Group Harness the Power of...