Groundwork Present

8/6/2019 Groundwork Present

1/15

ScenarioScenario

Esther, age 87, is a resident at aEsther, age 87, is a resident at a

Minnesota nursing home. She has beenMinnesota nursing home. She has been

there for three years. She was able tothere for three years. She was able towalk with a walker when she arrived, butwalk with a walker when she arrived, but

now needs a great deal of assistancenow needs a great deal of assistance

getting in and out of bed, and generallygetting in and out of bed, and generally

uses a wheelchair when out of her room.uses a wheelchair when out of her room.

Scenario source: Oregon Patient Safety Improvement Corps Team 2007/2008in collaboration with community and advocacy organizations


2/15

ScenarioScenario

One morning, Esther was being movedOne morning, Esther was being movedfrom her bed to a chair using a Hoyerfrom her bed to a chair using a Hoyer--typetypelift. She called for a CNA to help her.lift. She called for a CNA to help her.

As the CNA was moving her, Esther fellAs the CNA was moving her, Esther felland suffered a serious head injury as welland suffered a serious head injury as wellas some superficial scratches.as some superficial scratches.

Esther was briefly hospitalized forEsther was briefly hospitalized forevaluation of her head injury; a CTevaluation of her head injury; a CTshowed no intracranial bleeding, and sheshowed no intracranial bleeding, and shewas released the next day.was released the next day.


3/15

ScenarioScenario

During an investigation following the fall,During an investigation following the fall,

the CNA admitted that she did not followthe CNA admitted that she did not follow

the policy that required two staff membersthe policy that required two staff membersassist with all transfers.assist with all transfers.

The investigation found that the CNA wasThe investigation found that the CNA was

not compliant with the facilitys policy fornot compliant with the facilitys policy for

transfers.transfers.

She was given a warning and reShe was given a warning and re--trainedtrained

on the importance of the policy.on the importance of the policy.


4/15

How do we respond?How do we respond?

Look for the individual who was at faultLook for the individual who was at fault

Focus on training, compliance with policiesFocus on training, compliance with policies

BUT..BUT..

What if it happens again?What if it happens again?

What if someone else does the sameWhat if someone else does the samething?thing?

What if it goes deeper than that?What if it goes deeper than that?


5/15

What is RCA?What is RCA?

Root Cause AnalysisRoot Cause Analysis

Structured way of looking at events from aStructured way of looking at events from a

systemssystems perspectiveperspective

Events are rarely just the fault of one person doingEvents are rarely just the fault of one person doing

the wrong thingthe wrong thing

People operate in a system. The system can make itPeople operate in a system. The system can make it

easier for them to do the right thing, or more difficulteasier for them to do the right thing, or more difficult

Have to look at multiple contributing factorsHave to look at multiple contributing factors

If you dont uncover all potential causes, event canIf you dont uncover all potential causes, event can

happen againhappen again


6/15


Grew out of theories of accident analysis,Grew out of theories of accident analysis,systems design, safety engineeringsystems design, safety engineering

Required by the Joint Commission inRequired by the Joint Commission inresponse to sentinel eventsresponse to sentinel events

Required by Veterans AdministrationRequired by Veterans Administration

Used primarily in hospitals, but starting toUsed primarily in hospitals, but starting to

be used in some nursing homesbe used in some nursing homes OR, MD, some MN facilitiesOR, MD, some MN facilities

Compatible with MDH regulatory roleCompatible with MDH regulatory role


7/15


Facilitated ProcessFacilitated Process

After event: gather documents, assembleAfter event: gather documents, assemble

basic timelinebasic timelineAssemble all playersAssemble all players

Draw out the storyDraw out the story from all perspectivesfrom all perspectives

Work to identify contributing factorsWork to identify contributing factors Why, why, why, why, why?Why, why, why, why, why?

Develop plans of correction that addressDevelop plans of correction that address

contributing factorscontributing factors


8/15

ScenarioScenario

One morning, Esther was being movedOne morning, Esther was being movedfrom her bed to a chair using a Hoyer lift.from her bed to a chair using a Hoyer lift.She called for a CNA to help her.She called for a CNA to help her.

As the CNA was moving her, Esther fellAs the CNA was moving her, Esther felland suffered a serious head injury as welland suffered a serious head injury as wellas some superficial scratches.as some superficial scratches.

Esther was briefly hospitalized forEsther was briefly hospitalized forevaluation of her head injury; a CTevaluation of her head injury; a CTshowed no intracranial bleeding, and sheshowed no intracranial bleeding, and shewas released the next day.was released the next day.

Scenario source: Oregon Patient Safety Commission


9/15

ScenarioScenario

An investigation after Esthers fallAn investigation after Esthers fall

discovered the following:discovered the following:

The lift had been used many times before,The lift had been used many times before,and there were no known problems with it.and there were no known problems with it.

There were two lifts on the floor, but oneThere were two lifts on the floor, but one

was already in use.was already in use.

Both lifts were older models that requiredBoth lifts were older models that required

two people to use correctly.two people to use correctly.


10/15

ScenarioScenario

The CNA was aware of the policy requiringThe CNA was aware of the policy requiringtwo people for transfers with Hoyertwo people for transfers with Hoyer--typetypelifts. Before assisting Esther, she tried tolifts. Before assisting Esther, she tried to

find someone to help her. Of the two otherfind someone to help her. Of the two otherCNAs on duty, both were busy helpingCNAs on duty, both were busy helpingother residents.other residents.

The CNA was running behind in her work,The CNA was running behind in her work,and she knew that Esther tended to getand she knew that Esther tended to getagitated if she had to wait very long to getagitated if she had to wait very long to gethelp.help.


11/15

ScenarioScenario

The CNA had used this lift by herself beforeThe CNA had used this lift by herself before

without incident; she believed that shewithout incident; she believed that she

could use it safely again, so she made acould use it safely again, so she made a

decision to do the transfer unassisted.decision to do the transfer unassisted.

The CNA was trained in how to use the lift.The CNA was trained in how to use the lift.

When she was transferring Esther, she hadWhen she was transferring Esther, she had

to maneuver the lift around some obstaclesto maneuver the lift around some obstacles

in Esthers crowded room; this led toin Esthers crowded room; this led to

Esthers feet getting tangled in the lift,Esthers feet getting tangled in the lift,

making her lose her balance.making her lose her balance.


12/15

ScenarioScenario

Contributing factors for Esthers fall:Contributing factors for Esthers fall:

Environmental (crowded room, old lift)Environmental (crowded room, old lift)

Staffing (other staff busy, no plan for gettingStaffing (other staff busy, no plan for gettingassistance)assistance)

Policy (no provision for situations whenPolicy (no provision for situations when

backup not available)backup not available)

Culture (acceptance of shortcuts, individual vsCulture (acceptance of shortcuts, individual vsteam approach)team approach)


13/15

ScenarioScenario

Action Plan:Action Plan:

Explore purchase of lifts that can be used byExplore purchase of lifts that can be used byjust one person, are more stablejust one person, are more stable

Consider assistance with transfers whenConsider assistance with transfers whendeveloping workplans/priorities for staffdeveloping workplans/priorities for staff

Increased management followIncreased management follow--up to assessup to assesseffectiveness of modified workplanseffectiveness of modified workplans

Nurture team approach to care/lessNurture team approach to care/lessindividualized focus on rolesindividualized focus on roles


14/15

Two approachesTwo approaches

Focus on individual errorsFocus on individual errors

Individual blameIndividual blame

Punishing errorsPunishing errors

Expectation of perfectExpectation of perfect

performanceperformance

Solutions tend to beSolutions tend to be

disciplinary or focused ondisciplinary or focused on

trainingtraining

Focus on conditions thatFocus on conditions that

allow errors to happenallow errors to happen

Changing systemsChanging systems

Learning from errorsLearning from errors

Expectation of professionalExpectation of professional

performance within a systemperformance within a system

that compensates for humanthat compensates for human

limitationslimitations

Solutions might involveSolutions might involve

training, equipment, culturaltraining, equipment, cultural

change, staffingchange, staffing


15/15

Whats in it for you?Whats in it for you? Enhanced engagement/ownership by staffEnhanced engagement/ownership by staff

Empowers staff/Fosters creativityEmpowers staff/Fosters creativity

Process/systems focusedProcess/systems focused

Fosters more inFosters more in--depth analysisdepth analysis Assists you in completing the required Vulnerable AdultAssists you in completing the required Vulnerable Adult

documentation/analysisdocumentation/analysis

Risk preventionRisk prevention Staff are more proactiveStaff are more proactive --Identify risks in environmentIdentify risks in environment

Culture ChangeCulture Change more awareness of resident safetymore awareness of resident safetyand how staff can impact thisand how staff can impact this NonNon--punitive (Just Culture)punitive (Just Culture)

Documents

Groundwork Present