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
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Buy-in
Decisions
Education/training
Getting buy-in
• Need commitment from your organization
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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.