Welcome to this session on Root Cause Analysis, I'm Melody Malone, a Quality Improvement Consultant with TMF Health Quality Institute and we're happy to bring this QAPI Series. In this session, we will be discussing the root cause analysis, or you might care it refer to as the RCA. This program works hand and hand with the program on human factors and just culture. I hope that you'll do them all as you work through your quality improvement effort. But before we begin, talking about the root cause analysis, and how to implement the root cause analysis. We want to strive to learn about our mistakes and errors because we must never forget the potential human toll as a result of both clinical errors and errors in our business practices. Even though we'll speak a lot about daily in our quality improvement work, we must always remember that each piece of data may actually have hurt a human being, or has a potential to hurt someone. Every resident matters, every staff member matters and every guest and visitor matters. So, as you begin working through your quality improvement process and you're looking at data. Have you ever said to yourself, "How can my facilities here and how do I get to be like the top 10 in Texas, or some other benchmarking you maybe use?" You may ask yourself these questions. What can I get my facility where I want? Why I can't I sustain improvements? Well, when you look at a national benchmark, or a state benchmark, and go man, I want to get down to zero. I want to get closer to zero like these folks. Why I can't sustain improvements? Why I cant my data look like this? Well it's because most likely in your quality improvement efforts we haven't been able to find the real root cause. So, we're constantly trying to fix a problem but we're not fixing it with sustainable improvement. So, the root cause is the real reason why our problem has happened. It's a real set of circumstances that allowed the event or issue that your investigating that had happen. The search for the root cause will work best if you think of it somewhat like a CSI, a Crime Scene Investigator. Now I'm not saying that every event is a true crime. But most of us have seen at least one television show or movie in which the reason for the event would not what we originally thought, right? Well, when we're looking at our quality improvement problem, we as clinicians maybe thinking about this as the assessment or the evaluation step in our clinical process. And before we can begin to identify the proper plan and care, we have to thoroughly examine the residents, the same as true when we're trying to identify our sustainable changes in the quality improvement for our care and services. If we do not know the true reasons, we cannot fix it with sustainable changes. So the goal of root cause analysis is to identify what really happened? And why did it really happen? And what do we do to prevent it from happening again. So, the root cause analysis is a thorough in depth digging deeper dive trying to identify the why, why, why, why, why cause and effect of our problem. It's a very interdisciplinary approach and we want to ensure that we're always involving experts from our front line staff. And remember, those people on the front lines who are delivering the care and doing the job are experts are their jobs as they are designed today. So don't think of an expert merely as an outside consultant. Although remember people from the outside may have a new perspective. So, don't forget to include your residents and your family members and guests in your root cause analysis. They may have excellent information to give you. But the root cause analysis is also a "no blame exercise". We don't want to assume one individual is responsible for the error or the problem. We want to dig deeper to find the true root cause or causes. And don't be surprise if you uncover multiple aspects have played into your problem. Oftentimes, there is not only one root cause but multiple root causes. But because this could be a very uninteresting investigation process, it's difficult to provide you a tool that's going to work for every problem. Again it's that kind of crime scene investigator, we never know what [inaudible] terribly may have to hop down. So, we're going to show you several different kinds of tools to help you search for the why, why, why, why, why and the five why's tool is a great tool to use. It's available for you in our QAPI resource button on our website at the nursing home network. The way this work is you write down the specific problem in the problem statement, and then the team begins asking why did that happen and then why that? And why that? And when you get down to the bottom, whatever that may be, you may use all five whys, you may use a few, you may use more whys. But when you get to the root causes, when you remove that root cause then that event would be prevented. If you don't get to that point then the event will not have been prevented. You did not identify the true root cause. So let's look at the root cause five whys completed. So why is there no report of the changes in condition? So that's the problem they're trying to deal with. Well because the report communication between the staff, but why is that? 'Cause they're not using the proper tools the 24 hour report and then handoffs. Well why not? They don't have time. But why not, well they're not efficient with care in documentation. Well why is that? Lack of planning and training. So this team might identify that they had lack of planning and training on the 24 hour reporting, lack of training on the handoff and lack of implementing the handoff. So when they finally fix these items, they feel that they will have solved their problem of no reporting of changes and condition for the residents. So, the five whys tool is what tool you may choose to use. There's another tool called brainstorming, and there're really two versions. So, the first one we're going to discuss is brainstorming with our out loud voice. This helps to create or generate creative solutions to a problem for a specific member of a specific problem by gathering a list of ideas spontaneously contributed by your team. But there are some rules that go along with this because the important part is you want to encourage as much participation and anything that would keep someone for speaking up is going to be discouraging. So, to one brainstorming it's best to have a flip chart and markers but you could do it on a white board and then have someone take the notes later of what was recorded. To run brainstorming you go around they room and ask each person to throw out an idea without having anyone else comment positive or negative on the idea. The faster you move, the more the participants will add ideas and be encouraged to speak up. The more wide the better 'cause you never know what idea might be the one that is the solution. And in the end, you will force specific problem had gathered this list of ideas spontaneously contributed by your team. But you want to make sure every time you go to bring storming that you review the rules because if there's any judgment on someone's idea. Oh that was really greater. That's weird. It may prevent someone else from speaking out. And we don't want to do that 'cause every idea has equal worth. And then when you're finished generating all of these ideas then the team can go back and processed it and get clarification and understand further. So, if we were going to generate a list of ideas for that same problem before, why is there no change--reported changes in the residents condition? Our team may have generated these lists and then after we got this list pulled together we could go back and find what was our root cause, we want to begin a test of change on. Another root cause analysis tool is brainstorming but silent brainstorming. And I want this one, or sticky note brainstorming you may have heard it like that. So in silent brainstorming, you're still asking that why, why, why but people are writing them down on individuals sticky notes. So again, you'd have your flip chart, have your idea up there that you're brainstorming, and then as people have ideas they write them down, one idea per sticky note. And what this does is it really helps generate ideas but it lets people do it in a way where they may something with their sticky note in writing, they might not say with your out loud voice. But again, at the end you're going to process these ideas, you know, remove any duplicates, confirm meaning and then in that way you can get to try to identify have we understood the root cause. Another root cause analysis tool is the fishbone diagram. You may have also heard it called the Ishikawa diagram. This is another way in which you can sort ideas. You can brainstorm write on the diagram, or you can diagram after brainstorming, or after a five whys. But the way that this is works is at what the fish head is, you would write in your problem statement and then the ribs of the fishbones you put in what are your general topic ideas that you want to group your concerns into. So, I've listed for you categories of staff, material, equipment on education. You may come up with other things, such as methods, machine, measurement, or environment. So, here is an example of a fishbone completed with the same issue why is there no report of changes in the residents condition but this team is now group in other different categories. And they've identified what their issues are, such as the staff don't understand the process; or under education, ship management skills are lacking; or under equipment, the 24 hour book is in different locations at different nurse station. So, whatever tool you use, it helps you get to the real root cause. Ands eventually, you have to decide what is the root cause or causes for your problem. And remember you may have several, so once the root cause is completed, I want you to consider one more thing, consider human factors. Now, we do have a session on human factors. I hope that you'll listen to that session as well but if we don't consider human factors, we won't really have done a thorough root cause analysis. So, as you complete your root cause analysis, considering human factor then you'll be able to move on to the model for improvement. So here is your next step. Identify what problem you want to investigate. Decide the right team members. Remember, we want expert's closes to the problem and don't forget some of those outside people who may have a fresh perspective. So let your root cause analysis tool to trial. You can always change, and then run your analysis considering human factors. Then move on to the model for improvement so you can test your change and see if it will affect your quality improvement and get you to a sustainable level of higher quality. Good luck in your journey and in your root cause analysis. Contact us if we can be of service.