Transcript ppt - WHA Quality Center

INTERACT with QAPI
Conducting Root Cause Analysis
Foundational Track
October 30, 2013
Educational Credits for Today’s
Webinar
CPHQs – NAHQ approved
Nursing Home Administrators NAB-NCERS approved
Nurses – approved nsg. contact hours
Physicians – AMA PRA Category 1 CreditTM
PTs – WPTA approved
Social Workers – NASW approved
Dietitian – pending from CDR
Attendance Verification for
Credits
 Full SERIES attendance (four webinars) and
 Evaluation: Copy and enter into your web browser:
http://www.surveymonkey.com/s/Interact10-3013
 Social Workers – post-test required (is part of eval)
 Everyone please complete the online evaluation – thank
you!
Disclosures
No commercial support for webinar
Speaker or planner conflicts of interest –
None
Learning Objectives
Following this webinar, you will be able to:
 Identify best practices for the RCA process
 Use the Acute Care Transfer Log Tool to determine
causative factors that relate to unnecessary readmissions
 Use the Quality Improvement Tool for Review of
Acute Care Transfers
 Use the Quality Improvement Summary Worksheet
Today’s Presenters
Jody Rothe, RN, WCC
Stephanie Sobczak, MS, MBA
Connie Gliniecki, RN, DON
INTERACT with QAPI
Root Cause Analysis Webinar
Notes for Logging into INTERACT with QAPI Webinar Series:
 Please dial into the 1-800 phone line separately from your computer’s webinar login steps.
 Please MUTE your computer speakers during the webinar.
 Never place your phone on HOLD during the webinar.
 Unless you are speaking, please MUTE the phone line by selecting *6.
 You can un-MUTE your phone line to speak by selecting *7.
 Keep intentional background noise to a minimum during the webinar.
By following these instructions, a better webinar experience
will be possible for all participants.
Thank you.
INTERACT with QAPI
7
Collaborating Organizations
And our Expert Advisory Panel:
•Barb Beardsley - DON, Brookside Care Center
•Connie Gliniecki - DON, Kennedy Park Nursing and Rehab Center
•Lisa Gervais - NHA, Pine Crest Nursing Home
•Kristen Strother - MSW, Manager of Social Work, Case Management
and Abuse Response Services, Aurora Sinai Medical Center
INTERACT with QAPI
8
Today’s Agenda
1. Sharing from Connie
2. Best Practice Processes for Conducting a
Root Cause Analysis (RCA)
3. AE Safely Reduce Hospitalization Tool
4. The QI Tool for Review of Transfers
5. QI Summary Worksheet
6. Suggested Action Steps
INTERACT with QAPI
9
INTERACT with QAPI
10
From the Expert
Connie Gliniecki - DON, Kennedy Park Nursing
and Rehab Center
• The importance of doing an RCA
• What works well and what doesn’t
• Learning from the process
• Part of QAPI
• Should be completed by any staff at the time
of an identified problem
INTERACT with QAPI
11
From the Beginning…
 Do you have a consistent process for
conducting RCAs?
 Are the same people leading or instructing
others in the RCA?
 How are the caregivers involved with the
patient included in the RCA?
INTERACT with QAPI
12
Best Practices for RCA
1. Involve those who worked with the
resident– interview them
2. Follow the Tool and assess all the questions
3. Meet to compare findings and determine
what the cases have in common
4. If there is not a clear root cause, use the 5
Why Approach
INTERACT with QAPI
13
Best Practices for RCA
1. Involve those who worked with the
patient – interview them
2. Follow the Tool and assess all the questions
3. Meet to compare findings and determine
what the cases have in common
4. If there is not a clear root cause, use the 5
Why Approach
INTERACT with QAPI
14
Best Practices for RCA
1. Involve those who worked with the patient
– interview them
2. Follow the Tool and assess all the
questions
3. Meet to compare findings and determine
what the cases have in common
4. If there is not clear root cause, use the 5
Why Approach
INTERACT with QAPI
15
INTERACT QI Tool
INTERACT with QAPI
16
INTERACT QI Tool
Which of these are most common?
Helps you determine which processes
might be improved or refined.
INTERACT with QAPI
17
INTERACT QI Tool Example
INTERACT with QAPI
18
Introducing the Tool to Staff
First have at least one experienced staff person
review tool and try RCA with one case.
To continue;
• Option 1- Introduce the RCA with one staff
person at a time and ask them to fill out the
QI tool
• Option 2- Introduce the RCA to the team and
ask them to Interview people involved with a
recent readmission
INTERACT with QAPI
19
Best Practices for RCA
1. Involve those who worked with the patient
– interview them
2. Follow the Tool and assess all the questions
3. Meet to compare findings and determine
what the cases have in common
4. If there is not clear root cause, use the 5
Why Approach
INTERACT with QAPI
20
INTERACT QI Summary Worksheet
INTERACT with QAPI
21
INTERACT QI Summary Worksheet
INTERACT with QAPI
22
Best Practices for RCA
1. Involve those who worked with the patient
– interview them
2. Follow the Tool and assess all the questions
3. Meet to compare findings and determine
what the cases have in common
4. If there is no clear root cause, use the 5
Why Approach
INTERACT with QAPI
23
The 5 Why Approach
Case Example:
Two patients were sent to the hospital in the
past 2 weeks because of decreased fluid
intake or very low urinary output. In both
cases the physician determined patients were
dehydrated, and after giving fluids, each was
able to return to the facility.
INTERACT with QAPI
24
The 5 Why Approach
Mrs. Adams’ dehydration:
She was refusing to drink water
Why?
She will only drink bottled water
Why?
Her daughters tell her bottled water is better for her
and bring her a supply of bottled water.
 She was out of bottled water, so we need to supply
bottled water.
INTERACT with QAPI
25
The 5 Why Approach
Mr. Brown’s dehydration:
No history of swallowing difficulties but was
dehydrated
Why?
Patient had mentioned a sore throat
Why?
Patient had an endoscopy 3 days ago and hasn’t been
drinking water at bedside or meals.
 Throat pain caused by procedure that staff were
not aware of; were unaware of degree of
discomfort for the patient.
INTERACT with QAPI
26
The 5 Why Approach
Mr. Brown’s dehydration:
Throat pain caused by procedure that staff
were not aware of; were unaware of degree of
discomfort for the patient.
Why was staff unaware of the procedure?
The physician’s note and follow-up instructions
were not received.
Why?
 No standard process with clinics for
information/follow-up after appointments.
INTERACT with QAPI
27
Commonly Discovered
Root Causes
Communication breakdowns:
•
•
•
•
Missed signs of resident condition changes
Staff respond to clinical situations differently
Handoff problems with other organizations
INTERACT Tools not consistently used
INTERACT with QAPI
28
Prioritizing Findings
• Come to a group consensus on the top 2 or 3
things that could be improved based on your
Root Cause Analysis
• Update your QAPI Goal Setting Worksheet
INTERACT with QAPI
29
QAPI
• Use QAPI Toolkit for your performance
improvement plan
• Revisit your Goal Setting Worksheet to
update your plan based on your finding from
the Root Cause Analysis
INTERACT with QAPI
30
How INTERACT Links to Root Causes
Communication breakdowns
 SBAR
Missed signs of resident condition changes
 Stop and Watch Tool
Staff respond to clinical situations differently
 Care Pathways
Handoff problems with other organizations
 Transfer Tools
INTERACT with QAPI
31
Make a Plan to Do the Improvements
What?
What will you do for action steps?
Who?
Who will do the work? Who should be involved?
When?
When should steps be completed by?
How?
How will you make progress?
How will you know progress is on track?
INTERACT with QAPI
32
“How is it Going” Checklist
 Are you meeting as a team?
 Is data being gathered and submitted in a
timely way?
 Have you agreed upon clear next steps
 Have you connected with other staff to
participate in the effort?
 Are you updating your QAPI Goals
Worksheet?
INTERACT with QAPI
33
Recommended Action Items
Root Cause Analysis Action Items
1. Determine who is involved in tracking
transfers; check on data submission
2. Review 3-5 Acute Care Transfers with the
team; use QI Tool and determine root
causes
3. Modify your QAPI Goal Setting
Worksheet (your PIP) and develop a plan
4.
Submit
data
INTERACT with QAPI
34
Online Resources
Recorded Webinars available on:
Wisconsin Clinical Resource Center
https://wcrc.chsra.wisc.edu
(Requires your WCRC Username and Password)
WHA Quality Center
http://www.whaqualitycenter.org/LearningOpportunities/INTERACTwithQAPI.aspx
Other resources:
INTERACT Website
http://interact2.net/
MetaStar QAPI Resources
http://www.metastar.com/web/Default.aspx?tabid=573
Advancing Excellence – Safely Reduce Hospitalizations Tracking Tool (Data spreadsheet)
http://www.nhqualitycampaign.org/star_index.aspx?controls=hospitalizationsidentifybaseline
INTERACT with QAPI
35
References
INTERACT with QAPI
36
Attendance Verification for
Credits
 Full SERIES attendance (four webinars) and
 Evaluation: Copy and enter into your web browser:
http://www.surveymonkey.com/s/Interact10-3013
 Social Workers – post-test required (is part of eval)
 Everyone please complete the online evaluation – thank
you!
Contact Information:
Jody Rothe, RN, WCC
Quality Consultant
MetaStar, Inc.
2909 Landmark Place
Madison, WI 53713
Phone number: (608) 441-8271 or (800) 362-2320
www.metastar.com
[email protected]
INTERACT with QAPI
38