The Reality of Root-Cause Analysis at the Facility
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The Reality of
Root-Cause Analysis
at the Facility
Maryruth Butler, MBA, NHA, RCA
President, Cascadia Northern Healthcare
Sue Goodrick, RN
Director of Clinical Resources, Cascadia Northern Healthcare
55th IHCA Annual Convention & Trade Show
Boise Centre Wednesday, July 14, 2021 1:30 pm – 3:00 pm
1
Learning Objectives
1. State what Root Cause Analysis means
and the importance of understanding
how it affects Quality Assurance and
Performance Improvement.
2. Identify RCA in examples based
on documented data.
3. Apply RCA to promote improvement
for identified areas of care in the
skilled nursing setting.
2
1
The Event
3
Individualized Interventions Worksheet
4
2
Equipment Safety Checklist
5
Equipment Safety Checklist
6
3
Value of Root-Cause Analysis
Leads to digging deeper and deeper,
looking for reasons behind the reasons
• Usually leads to more than one root cause
Once the root causes are identified,
they can be targeted by
system-level action
• In essence, the problem can be rooted out
7
Root Cause Analysis and its relationship to QAPI
Action Steps
to
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/QAPI/Downloads/QAPIAtaGlance.pdf
8
4
Getting to the “Root” of the Problem
RCA focuses primarily on systems and
processes, not individual performance
The RCA process takes practice
In order to get familiar with RCA
your team may consider:
• studying case examples of RCA
• applying RCA to an adverse event and
discussing this technique with the team
• building RCA examples into training opportunities
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/QAPI/Downloads/QAPIAtaGlance.pdf
9
STEP 1 to Conduct an RCA
Step
Step 7 Measure the Success of Changes
Step 6 Design and Implement Changes
Step 5 Identify the Root Causes
Step 4 Identify the Contributing Factors
Step 3 Describe What Happened
Step 2 Charter and Select Team Facilitator and Team Members
1 Identify the Event to be Investigated and Gather Preliminary Information
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/GuidanceforRCA.pdf
https://stratishealth.org/toolkit/root-cause-analysis-toolkit-for-long-term-care/
10
5
Step Identify the Event to be Investigated
1 and Gather Preliminary Information
Incident Report
Risk Management
Staff, Resident, or Family Feedback
Near Miss or Close Call
11
Step Identify the Event to be Investigated
1 and Gather Preliminary Information
Start with the Problem,
not the Solution
Don’t be tempted to know
what will fix the problem
before thoroughly examining it
12
6
Process Flow Fall Occurrence for Licensed Nurses
4.
Notify the Primary Care
Provider and Family
1. 6.
Evaluate and Falls 8.
3.
Fall Monitor Patient 5. Assessment Monitor
Record
Circumstances, Immediate Implementation
Patient Outcome, Intervention and
2. 7. Patient Response
and Staff Response
Investigate Care Plan
Circumstances
First 24 Hours 1 – 7 Days 1 – 6 Months
13
STEP 2 to Conduct an RCA
Step
Step 7 Measure the Success of Changes
Step 6 Design and Implement Changes
Step 5 Identify the Root Causes
Step 4 Identify the Contributing Factors
Step 3 Describe What Happened
Step 2 Charter and Select Team Facilitator and Team Members
1 Identify the Event to be Investigated and Gather Preliminary Information
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/GuidanceforRCA.pdf
https://stratishealth.org/toolkit/root-cause-analysis-toolkit-for-long-term-care/
14
7
Step
2 Select Team Members – Who to Involve
People who have skills that support the
process and systems associated with the event
Those with personal knowledge of the event
Those who may have knowledge of the resident
over last 24 hours:
• Housekeeping
• Activities
• Social Services
15
STEP 3 to Conduct an RCA
Step
Step 7 Measure the Success of Changes
Step 6 Design and Implement Changes
Step 5 Identify the Root Causes
Step 4 Identify the Contributing Factors
Step 3 Describe What Happened
Step 2 Charter and Select Team Facilitator and Team Members
1 Identify the Event to be Investigated and Gather Preliminary Information
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/GuidanceforRCA.pdf
https://stratishealth.org/toolkit/root-cause-analysis-toolkit-for-long-term-care/
16
8
Step
3 Describe What Happened
Create a Timeline
• Describe the facts surrounding event
• Tell the “story” of the event
Stick to the Facts
• Causal factors can be added later
Refrain from a “Quick Fix”
• Don’t jump to conclusion too quickly
• Quick fixes often do not fix the root cause
17
“Be Curious, Not Judgmental” –Walt Whitman
Avoid Tunnel Vision
Avoid the Blame Game:
Focus on the "how"
and the "why"
not on the "who"
RCA is not intended to find
“who is at fault”
https://empira.org/application/files/6616/0582/1736/Empira_Fall_Prevention
_and_Reduction_Program.pdf
18
9
Staff’s 10 Questions at the Time of a Patient Fall
1. Ask the resident: Are you OK?
2. Ask the resident: What were you trying to do when you fell?
3. Ask the resident or determine, what was different this time?
4. Position of the resident when they fell?
a. Did they fall near a transfer surface such as a bed,
toilet, or chair? If so, how far away from the surface
were they: __Next to the surface __5–7 feet away
__Greater than 15 feet away
b. Were they on their back, front, L side, or R side?
c. What was the position of their arms and legs?
19
Staff’s 10 Questions at the Time of a Patient Fall
5. What was the surrounding area like?
a. Noisy? Busy? Cluttered?
b. If in the bathroom, contents of the toilet?
c. Poor lighting – visibility?
d. Position of the furniture and equipment? Bed height correct?
6. What was the floor like?
a. Wet floor? Urine on the floor? Uneven floor? Shiny floor?
b. Carpet or tile?
20
10Staff’s 10 Questions at the Time of a Patient Fall
7. What apparel was the resident wearing?
a. Shoes, socks (non-skid?), slippers, bare feet?
b. Poorly fitting clothes (too long or big)?
8. Was the resident using an assistive device?
a. Cane b. Walker c. Wheelchair d. Merry Walker e. Other:
9. Did the resident have glasses and/or hearing aides on?
10. Who was in the area when the resident fell?
21
Clinical Review for Resident Falls Checklist
22
11Clinical Review for Resident Falls Checklist
23
STEP 4 to Conduct an RCA
Step
Step 7 Measure the Success of Changes
Step 6 Design and Implement Changes
Step 5 Identify the Root Causes
Step 4 Identify the Contributing Factors
Step 3 Describe What Happened
Step 2 Charter and Select Team Facilitator and Team Members
1 Identify the Event to be Investigated and Gather Preliminary Information
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/GuidanceforRCA.pdf
https://stratishealth.org/toolkit/root-cause-analysis-toolkit-for-long-term-care/
24
12Step
4 Identify the Contributing Factors
Contributing factors may not have
caused the incident but when they
occur at same time the risk increases
Importance of Staff Questions
• Question staff as if not
personally involved in event
• Staff may not understand
contributing factors existed
25
Step
4 Identify the Contributing Factors
Try to get Written Statements
Interview if possible:
Resident
Resident Roommate
Similar Residents
Staff
Volunteers
Family
26
133 Areas to Investigate to Effectively Conduct an RCA
Internal / Intrinsic Conditions
Environment / Extrinsic Conditions
Operational / Systemic Conditions
https://empira.org/application/files/6616/0582/1736/Empira_
Fall_Prevention_and_Reduction_Program.pdf
27
The 4 Ps – The Unmet Needs to Check
Position
Placement
The Personal
(Potty)
4 Ps Needs
Pain
https://empira.org/application/files/6616/0582/1736/Empira_
Fall_Prevention_and_Reduction_Program.pdf
28
14SAFE Medication Review Framework
*
*
https://www.cdc.gov/steadi/pdf/STEADI-FactSheet-SAFEMedReview-508.pdf
29
Side
Effects
Warning May Lead
Fall to Falls
Risk
30
15STEP 5 to Conduct an RCA
Step
Step 7 Measure the Success of Changes
Step 6 Design and Implement Changes
Step 5 Identify the Root Causes
Step 4 Identify the Contributing Factors
Step 3 Describe What Happened
Step 2 Charter and Select Team Facilitator and Team Members
1 Identify the Event to be Investigated and Gather Preliminary Information
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/GuidanceforRCA.pdf
https://stratishealth.org/toolkit/root-cause-analysis-toolkit-for-long-term-care/
31
Step
5 Identify the Root Causes
There can be more than one root cause to an event
Contributing factors are not root causes
The team must determine a
true root cause vs. contributing factors
which may require more investigating
32
16Step
5 Root Cause Identification Flow Chart
Would the event have occurred if
this cause had not been present?
Root Cause has
YES NO
been identified.
Will the problem recur if this
cause is corrected or eliminated?
YES Root Cause has
NO
been identified.
Continue to ask questions until you receive a NO,
identifying the Root Cause.
33
The Fishbone Tool
A visual way to look at
cause and effect
Helps in brainstorming
to identify possible
causes of a problem
Helps in sorting ideas
into useful categories
Offers a more
structured approach
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/QAPI/Downloads/FishboneRevised.pdf
34
17Fishbone Diagram Example
Sample Categories
Sample Causes
Problem
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/QAPI/Downloads/FishboneRevised.pdf
35
The Five Whys Tool
The Strategy: Look at any problem and drill down Why?
Why?
by asking: “Why?” or “What caused this problem?”
• Keep asking/answering until arrive at answer revealing
Why?
Why?
incident would have been prevented if the identified
causes and contributing factors had not been present
Why?
Why?
Simple problem-solving technique
Gets to the root of a problem quickly
Why?
Why?
Understanding the contributing factors or causes
can help develop actions that sustain corrections
Why?
Why?
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/QAPI/Downloads/FiveWhys.pdf
36
18Five Whys Everyday Example
Problem Statement Once sentence description of event or problem.
Your car gets a flat tire on the way to work.
Why? Why did you get a flat tire?
Why? Why were there nails on the garage floor?
Why? Why was the box of the nails wet?
Root Cause(s)
1) You ran over nails in your garage
If you stopped here 2) The box of nails on the shelf was wet; the box fell
and “solved” the apart and the nails fell from the box onto the floor
problem by sweeping
up the nails, you 3) There was a leak in the roof and it rained hard
would have missed last night.
the root cause of the To validate root cause, ask the following: If you removed this
problem! root cause, would this even or problem have been prevented?
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/QAPI/Downloads/FiveWhys.pdf
37
Found on floor beside sink
Bad Example
Tried to get up by self
Confused
Self transfer with confusion
https://www.health.state.mn.us/facilities/patientsafety/adverseevents/toolkit/
38
19Resident found on floor adjacent to bed in room
Good Example
Lost balance during ambulation
Leaning against privacy curtain
Thought the privacy curtain
was the wall
Privacy curtain is similar
color as the wall
Facility decor
Solution:
Resident lost balance and fell
changed
when she leaned against privacy curtain
thinking it was the wall curtain color
as indicated
https://www.health.state.mn.us/facilities/patientsafety/adverseevents/toolkit/
39
STEP 6 to Conduct an RCA
Step
Step 7 Measure the Success of Changes
Step 6 Design and Implement Changes
Step 5 Identify the Root Causes
Step 4 Identify the Contributing Factors
Step 3 Describe What Happened
Step 2 Charter and Select Team Facilitator and Team Members
1 Identify the Event to be Investigated and Gather Preliminary Information
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/GuidanceforRCA.pdf
https://stratishealth.org/toolkit/root-cause-analysis-toolkit-for-long-term-care/
40
20Step Design and Implement Changes
6 to Eliminate the Root Causes
Often times identification
of root cause may require
a new process or make
a change to a
current process
Remember to develop
at least one corrective action to
reduce or eliminate root cause
41
Questions to Ask When Developing
What safeguards are needed
to prevent recurrence?
What contributing factors might trigger this root cause?
How can we prevent?
How can we change things to make sure root cause does
not occur again?
What do we need to do to prevent this root cause from
happening to other residents?
42
21CMS Accidents Critical Element Pathway
A must have in
your Tool Kit!
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/CMS-20127-Accidents.pdf
43
STEP 7 to Conduct an RCA
Step
Step 7 Measure the Success of Changes
Step 6 Design and Implement Changes
Step 5 Identify the Root Causes
Step 4 Identify the Contributing Factors
Step 3 Describe What Happened
Step 2 Charter and Select Team Facilitator and Team Members
1 Identify the Event to be Investigated and Gather Preliminary Information
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/GuidanceforRCA.pdf
https://stratishealth.org/toolkit/root-cause-analysis-toolkit-for-long-term-care/
44
22Step
7 Measure the Success of Changes
Measure the effectiveness of the corrective action or
intervention 24 hours, 72 hours, and 7 days for the resident
What you measure should answer:
✓ Was the intervention actually put in place?
✓ Are employees following the new intervention?
✓ Has the intervention made a difference?
✓ Is the intervention effective?
45
4 P’s
Witness
Statements
Staff 10 and
Questions Investigation
Checklist
Medication
Environment Review
Fishbone
Tool and
5 Whys
Root Cause
46
23Process Flow Fall Occurrence for Licensed Nurses
4.
Notify the Primary Care
Provider and Family
1. 6.
Evaluate and Falls 8.
3.
Fall Monitor Patient 5. Assessment Monitor
Record
Circumstances, Immediate Implementation
Patient Outcome, Intervention and
2. 7. Patient Response
and Staff Response
Investigate Care Plan
Circumstances
First 24 Hours 1 – 7 Days 1 – 6 Months
47
CMS Guidance for Performing RCA with PIPs
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/QAPI/Downloads/GuidanceforRCA.pdf
48
24Five Elements for Framing QAPI in Nursing Homes
CMS has identified five strategic
elements that are basic building
blocks to effective QAPI.
These provide a framework
for QAPI development.
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/QAPI/Downloads/QAPIAtaGlance.pdf
49
Members
Interdisciplinary Team and
QAPI Committee Weekly Standards of Care Staff Meetings;
Monthly QAPI Meeting;
Daily Stand-Up Meeting Monthly Department Manager’s Meeting;
Annual Action Map Planning
Senior Leaders
Senior Leadership Rounds PDSA
Cycle
Departmental Workforce
Monthly
Nurse Staff → CNA’s → Therapy → Activities In-service
Training;
Patient Care Conferences Facility
Postings
Patients and Residents
50
25Update PI Plans with
information that
was accomplished
steps taken
performance
measures
51
“If you cannot measure it,
you cannot improve it.”
-Lord Kelvin
52
26Incident Tracking Log
53
2021 Total Falls Day of Week and Staff Shift
9
8
Total Number of Falls
7
1 3 3
6
3 3
5
4
3 6
5 1 5 5
2 4 4
1 2
0
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Days Evenings
54
272021 Total Falls at Time of Day
12 PM 12 AM 12 AM 12 PM LUNCH
11 AM 1 AM 11 PM 1 PM
1 Shift
1 0 1 Change
4 0 2 AM 1 1 2 PM
10 AM 10 PM
Shift
3 0 Change 0 2
9 AM 3 AM 9 PM 3 PM
6 0 3 2
8 AM 4 AM 8 PM 4 PM
2 1 2 3
BREAKFAST
3 3 3 3
7 AM 5 AM 7 PM 5 PM
6 AM Shift 6 PM DINNER
Change
55
Performance Improvement Action Plan Example
56
28Sustain the Change
57
Maryruth Butler, President
Cascadia Northern Healthcare
mbutler@cascadiahc.com
Sue Goodrick, Clinical Resources
Cascadia Northern Healthcare
sgoodrick@cascadiahc.com
58
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