Root Cause Analysis: Next Steps

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Root Cause Analysis Next Steps
Betsy Jeppesen Vice President, Program Integrity
Stratis Health
Sue Ann Guildermann Director of Education Empira

• Diane Rydrych
• Assistant Director, Division of Health
• Policy, Minnesota Department of Health

Linda Shell Corporate Director,
Education Volunteers of America
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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

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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?

4
Decisions to make

• When will you use RCA?
• Difficult issues youre 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

5
Staff Education

• Facilitator training
• Just in time training for staff
• Role of medical director, pharmacy, hospice,
  others who may be involved
• Orientation

6
Resources

• Reporting forms
• Tools/visuals for timelines or root cause
  diagrams
• Training forms for staff

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The hard part

• Doing the RCA is not the most difficult part
• The challenge comes from committing to your staff
  that youre going to do things in a different way
  truly examine root causes.
• You are asking for their trust. Are you going to
  follow through?

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Questions?

• Sue Ann Guildermann
• Director of Education
• Empira
• 952-259-4477
• sguilder_at_empira.org
• www.empira.org
• Diane Rydrych
• Assistant Director
• Division of Health Policy
• Minnesota Department of Health
• 651-201-3564
• Diane.rydrych_at_state.mn.us
• www.health.state.mn.us/patientsafety

• Betsy Jeppesen
• Vice President, Program Integrity
• Stratis Health
• 952-853-8510 or 877-787-2847
• bjeppesen_at_stratishealth.org
• www.stratishealth.org
• Linda Shell
• Corporate Director,
• Education and Learning
• Volunteers of America
• 651-503-8885
• lshell_at_voa.org

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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.