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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.
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.
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.
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.
3. Describe event
Collect and organize the facts surrounding the event to understand what happened.
4. Identify all factors
The situations, circumstances, or conditions that increased the likelihood of the event are identified, and analyzed.
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.
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.
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.
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
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