Root Cause Analysis: Next Steps Sue Ann Guildermann Betsy Jeppesen Director of Education Empira Vice President, Program Integrity Stratis Health Diane Rydrych Linda Shell Assistant Director, Division of Health Policy, Minnesota.
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Root Cause Analysis: Next Steps Sue Ann Guildermann Betsy Jeppesen Director of Education Empira Vice President, Program Integrity Stratis Health Diane Rydrych Linda Shell Assistant Director, Division of Health Policy, Minnesota Department of Health Corporate Director, Education Volunteers of America Where do we go from here? • We understand what RCA is and how to facilitate an RCA…..now what? • Planning for implementation Buy-in Decisions Education/training Getting buy-in • Need commitment from your organization – – – – Who makes the decisions? What do they need to know/understand? When & how will they decide? What do you need them to commit – resources, time, moral support? – Who is going to be responsible for making sure that corrective actions happen – that you are following through? Decisions to make • When will you use RCA? – Difficult issues you’re struggling with? – Highest risk for injury or death? – Frequency? • What criteria should you use? • What are the ramifications? – Resource needs – Education/training – Frequency of RCA Staff Education • Facilitator training • Just in time training for staff • Role of medical director, pharmacy, hospice, others who may be involved • Orientation Resources • Reporting forms • Tools/visuals for timelines or root cause diagrams • Training forms for staff The hard part • Doing the RCA is not the most difficult part… • The challenge comes from committing to your staff that you’re going to do things in a different way & truly examine root causes. • You are asking for their trust. Are you going to follow through? Questions? Sue Ann Guildermann Director of Education Empira 952-259-4477 [email protected] www.empira.org Betsy Jeppesen Vice President, Program Integrity Stratis Health 952-853-8510 or 877-787-2847 [email protected] www.stratishealth.org Diane Rydrych Assistant Director Division of Health Policy Minnesota Department of Health 651-201-3564 [email protected] www.health.state.mn.us/patientsafety Linda Shell Corporate Director, Education and Learning Volunteers of America 651-503-8885 [email protected] Protecting, maintaining, and improving the health of all Minnesotans. Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities.