Root Cause Analysis – Assisted Living - WHCA/WiCAL
Transcript of Root Cause Analysis – Assisted Living - WHCA/WiCAL
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Root Cause Analysis – Assisted Living
Frieda Pulkowski, RN, BSN, NHA, MS
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Definitions
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Physical
Human
Organizational
Common Causes
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Order within chaos…
Why?
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Proactive versus reactive living
Why?
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Performance improvement
Clinical versus non clinical indicators
What else…
Why?
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Team and roles
Meeting ground rules
Who?
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Selection and characteristics of performance measures/incidents and events to analyze
How?
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A word about data collection…
Ask the housekeeper AKA “You can’t handle the truth”
How?
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The questions to ask
How?
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Determining the root cause(s)
Is it controllable and fixable or not
How?
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Common “don’ts”
How?
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Caution….
Correlation versus
Causation versus
Coincidence
And….what about computers?!
How?
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Types of RCA
The 5 Whys
Fishbone/Ishikawa Diagram
Narrative Sequencing of Events
Others
How?
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Formatting the FP way
How?
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The Examples
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Plan and develop – typical approaches are:
Your method
Failure mode and effects
Impact analysis
Kaizen
Others
Next Steps
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Implement
Next Steps
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Evaluate
Next Steps
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Follow up
Next Steps
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Causal factor charting
What Else
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Q and A