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Root Cause Analysis – Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS

Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

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Page 1: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Root Cause Analysis – Assisted Living

Frieda Pulkowski, RN, BSN, NHA, MS

Page 2: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Definitions

Page 3: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Physical

Human

Organizational

Common Causes

Page 4: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Order within chaos…

Why?

Page 5: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Proactive versus reactive living

Why?

Page 6: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Performance improvement

Clinical versus non clinical indicators

What else…

Why?

Page 7: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Team and roles

Meeting ground rules

Who?

Page 8: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Selection and characteristics of performance measures/incidents and events to analyze

How?

Page 9: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

A word about data collection…

Ask the housekeeper AKA “You can’t handle the truth”

How?

Page 10: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

The questions to ask

How?

Page 11: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Determining the root cause(s)

Is it controllable and fixable or not

How?

Page 12: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Common “don’ts”

How?

Page 13: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Caution….

Correlation versus

Causation versus

Coincidence

And….what about computers?!

How?

Page 14: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Types of RCA

The 5 Whys

Fishbone/Ishikawa Diagram

Narrative Sequencing of Events

Others

How?

Page 15: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Formatting the FP way

How?

Page 16: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

The Examples

Page 17: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Plan and develop – typical approaches are:

Your method

Failure mode and effects

Impact analysis

Kaizen

Others

Next Steps

Page 18: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Implement

Next Steps

Page 19: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Evaluate

Next Steps

Page 20: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Follow up

Next Steps

Page 21: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Causal factor charting

What Else

Page 22: Root Cause Analysis – Assisted Living · 2017-11-02 · Root Cause Analysis –Assisted Living Frieda Pulkowski, RN, BSN, NHA, MS. Definitions ... Determining the root cause(s)

Q and A

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