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Root Cause Analysis Toolkit for Long-Term Care

Root Cause Analysis (RCA) is a problem solving method to investigate an actual or potential problem, incident or concern. A team looks beyond an immediate solution to understand the underlying cause(s) of the problem. Those causes are then changed to prevent the problem from happening again. For support using this toolkit, contact Kristi Wergin, 952-853-8561, or Kathie Nichols, 952-853-8590.

What is Root Cause Analysis and Why is It Valuable?
Start with this introduction to root cause analysis.
(16-minute video) transcript (6-page PDF)

How to Use the Root Cause Analysis Toolkit for Long Term Care.
A short intro to the toolkit.
(3-minute video)

Getting started

Root Cause Analysis is comprised of the seven steps identified below. When you select a step you will be presented with a table of resources related to this step. There are tools that will assist you in doing the step and an example of how to perform that step. There is one scenario that is used throughout all the steps to demonstrate a beginning to end effort.

Click on the steps to advance through the process.

Root Cause Analysis Toolkit Home Identify the event Select team Describe event Identify all factors Identify root cause Create change Communicate

1. Identify the event

The nursing home should have a process for selecting events that will undergo an RCA. Event and concerns can come from many sources.

 

# Tool Use Purpose Audience
1 When to Use the RCA Process Describes when to apply the RCA process. (2-page PDF) Instructions Team
2 Case Study Case study of an NH team using RCA to analyze a problem and make changes to prevent it from happening again. Case study is followed throughout RCA Toolkit. (3-page PDF) Example Team

2. Select team

Root cause analysis is always conducted by a team. This team identifies the root cause(s) of a single event and identifies, implements, and evaluate corrective actions to prevent the event from happening again. This step involves selecting a facilitator and team members.

 

# Tool Use Purpose Audience
1 Select Facilitator and Team Members Describes considerations for selecting a team facilitator and team members. (2-page PDF) Instructions Sponsor and Facilitator
2 Non-Punitive Culture A non-punitive culture vs. a blame culture. (2-page PDF) Instructions Team
3 Introduction to Creating a Just Culture Key concepts of Just Culture and why it is important to create an environment of free and open reporting. (53-minute webinar) Reference Team

3. Describe event

Collect and organize the facts surrounding the event to understand what happened.

 

# Tool Use Purpose Audience
1 Interview Guidelines Describes information for person conducting an interview for RCA. (2-page PDF) Instructions Team
2 Timeline Worksheet Describes how to use an RCA timeline and provides a worksheet for your use. (2-page PDF) Instructions Team
3 Timeline Worksheet Example Example of RCA Timeline based on case study. (2-page PDF) Example Team

4. Identify all factors

The situations, circumstances, or conditions that increased the likelihood of the event are identified, and analyzed.

 

# Tool Use Purpose Audience
1 Flowcharting Instructions Describes how to create a flowchart: A flowchart is a tool that allows you to break any process down into individual events or activities and shows the logical relationships between them. (2-page PDF) Instructions Team
2 Flowcharting Examples Examples of flowchart; current state and future state based on case study. (2-page PDF) Example Team
3 Fishbone Diagram Worksheet Describes the fishbone diagram process and provides a worksheet for your use. (3-page PDF) Instructions Team
4 Fishbone Diagram Worksheet Example Example of fishbone diagram based on case study. (1-page PDF) Example Team
5 Five Whys Worksheet Describes the five whys method for analyzing an event and provide a worksheet for your use. (2-page PDF) Instructions Team
6 Five Whys Worksheet Example Example of five whys based on case study. (1-page PDF) Example Team
7 Brainstorming, Affinity Grouping and Multi-Voting Describes techniques for identifying and ranking contributing factors. (3-page PDF) Instructions Team

5. Identify root cause

After identifying all the factors that contributed to the event, the team chooses one or more root causes. Root causes are those factors that if altered, would prevent the event from happening again.

 

# Tool Use Purpose Audience
1 Root Cause and Contributing Factors Worksheet Describes how to document root cause(s) and contributing factors. (2-page PDF) Instructions Team
2 Root Cause and Contributing Factors Worksheet Example Example of how to complete Root Cause and Contributing Factors Worksheet. (1-page PDF) Example Team

6. Change & measure

Creating change is the implementation step to make changes to processes and systems within the organization. The team develops a goal, measures, and implementation steps. The implementation steps are trailed using the Plan, Do, Study, Act (PDSA) cycle. These same steps are used for any quality improvement initiative.

 

# Tool Use Purpose Audience
1 Goal Setting Worksheet Describes how to set goals and provides a worksheet for your use. (2-page PDF) Instructions Team
2 Goal Setting Worksheet Example Example of how to complete the Goal Setting Worksheet. (2-page PDF) Example Team
3 Measure Development Worksheet Describes how to develop measures and provides a worksheet for your use. (3-page PDF) Instructions Team
4 Measure Development Worksheet Example Example of how to complete the Measure Development Worksheet. (3-page PDF) Example Team
5 Corrective Action Plan Worksheet Describes how to complete the Corrective Action Plan and provides a worksheet for your use. (3-page PDF) Instructions Team
6 Corrective Action Plan Worksheet Example Example of how to complete the Corrective Action Plan Worksheet. (1-page PDF) Example Team
7 PDSA Webinar Describes the fundamentals of the Model for Improvement and key concepts about testing changes on a small scale using Plan-Do-Study-Act (PDSA) cycles. (51-minute webinar) Reference Team
8 PDSA Cycle Worksheet Describes how to conduct a PDSA cycle and provides a worksheet for your use. (4-page PDF) Instructions Team
9 PDSA Cycle Worksheet Example Example of how to complete the PDSA Cycle Worksheet. (5-page PDF) Example Team
10 Measurement Guide for Long Term Care Defines measures that will support and demonstrate outcomes. (30-page PDF) Instructions Team

7. Communicate & sustain

In step 7 the team defines ways to assure the changes they have implemented are communicated and shared with residents, families, and staff. Measures for ongoing monitoring can be developed through use of a dashboard. Other tolls assist with communication and sustainability.

 

# Tool Use Purpose Audience
1 Instructions to Develop a Dashboard Use this tool to guide the process of developing a dashboard. The step are intended to help the team members understand the value of a dashboard and the process for creating a dashboard. (4-page PDF) Instructions Team
2 Improvement Success Story Template Use this template to tell the story of a change your nursing home made that led to a demonstrable improvement. (3-page PDF) Instructions Team
3 Communication Plan Worksheet Use this worksheet to plan communications about performance improvement projects. (3-page PDF) Instructions Team
4 Sustainability Decision Guide This is a resource to help leaders or teams determine if the interventions and changes they are making are sustainable. (2-page PDF) Instructions Team
Copyright © 2014 Stratis Health
Produced under contract with the Minnesota Department of Health
Produced with the use of Federal Nursing Home Civil Money Penalty Funds