INTERACT with QAPI

INTERACT with QAPI

Conducting Root Cause AnalysisFoundational Track

October 30, 2013

Educational Credits for Today’s WebinarCPHQs – NAHQ approved

Nursing Home Administrators - NAB-NCERS approved Nurses – approved nsg. contact hoursPhysicians – AMA PRA Category 1 CreditTM

PTs – WPTA approved Social Workers – NASW approvedDietitian – pending from CDR

Attendance Verification for Credits

Full SERIES attendance (four webinars) and Evaluation: Copy and enter into your web browser:

http://www.surveymonkey.com/s/Interact10-30-13 Social Workers – post-test required (is part of eval) Everyone please complete the online evaluation – thank you!

Disclosures

No commercial support for webinar

Speaker or planner conflicts of interest – None

Learning ObjectivesFollowing this webinar, you will be able to: Identify best practices for the RCA processUse the Acute Care Transfer Log Tool to determine causative factors that relate to unnecessary re-admissionsUse the Quality Improvement Tool for Review of Acute Care TransfersUse the Quality Improvement Summary Worksheet

Today’s Presenters

Jody Rothe, RN, WCC

Stephanie Sobczak, MS, MBA

Connie Gliniecki, RN, DON

INTERACT with QAPIRoot Cause Analysis Webinar

INTERACT with QAPI 7

Notes for Logging into INTERACT with QAPI Webinar Series: Please dial into the 1-800 phone line separately from your computer’s webinar login steps. Please MUTE your computer speakers during the webinar. Never place your phone on HOLD during the webinar. Unless you are speaking, please MUTE the phone line by selecting *6. You can un-MUTE your phone line to speak by selecting *7. Keep intentional background noise to a minimum during the webinar.

By following these instructions, a better webinar experience will be possible for all participants.

Thank you.

Collaborating Organizations


And our Expert Advisory Panel:•Barb Beardsley - DON, Brookside Care Center•Connie Gliniecki - DON, Kennedy Park Nursing and Rehab Center•Lisa Gervais - NHA, Pine Crest Nursing Home•Kristen Strother - MSW, Manager of Social Work, Case Management and Abuse Response Services, Aurora Sinai Medical Center

Today’s Agenda

1. Sharing from Connie2. Best Practice Processes for Conducting a

Root Cause Analysis (RCA)3. AE Safely Reduce Hospitalization Tool4. The QI Tool for Review of Transfers5. QI Summary Worksheet6. Suggested Action Steps



From the Expert

Connie Gliniecki - DON, Kennedy Park Nursing and Rehab Center•The importance of doing an RCA•What works well and what doesn’t•Learning from the process•Part of QAPI•Should be completed by any staff at the time of an identified problem

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From the Beginning…

Do you have a consistent process for conducting RCAs?

Are the same people leading or instructing others in the RCA?

How are the caregivers involved with the patient included in the RCA?


Best Practices for RCA

1. Involve those who worked with the resident– interview them

2. Follow the Tool and assess all the questions3. Meet to compare findings and determine

what the cases have in common4. If there is not a clear root cause, use the 5

Why Approach



1. Involve those who worked with the patient – interview them


what the cases have in common4. If there is not a clear root cause, use the 5

Why Approach




2. Follow the Tool and assess all the questions

3. Meet to compare findings and determine what the cases have in common

4. If there is not clear root cause, use the 5 Why Approach


INTERACT QI Tool


INTERACT QI Tool


Helps you determine which processes might be improved or refined.

Which of these are most common?

INTERACT QI Tool Example


Introducing the Tool to Staff

First have at least one experienced staff person review tool and try RCA with one case.To continue;•Option 1- Introduce the RCA with one staff person at a time and ask them to fill out the QI tool•Option 2- Introduce the RCA to the team and ask them to Interview people involved with a recent readmission





what the cases have in common4. If there is not clear root cause, use the 5

Why Approach


INTERACT QI Summary Worksheet


INTERACT QI Summary Worksheet





what the cases have in common4. If there is no clear root cause, use the 5

Why Approach


The 5 Why Approach


Case Example:Two patients were sent to the hospital in the past 2 weeks because of decreased fluid intake or very low urinary output. In both cases the physician determined patients were dehydrated, and after giving fluids, each was able to return to the facility.

The 5 Why Approach


Mrs. Adams’ dehydration:She was refusing to drink water

Why?She will only drink bottled water

Why?Her daughters tell her bottled water is better for her

and bring her a supply of bottled water. She was out of bottled water, so we need to supply

bottled water.

The 5 Why Approach


Mr. Brown’s dehydration:No history of swallowing difficulties but was

dehydrated Why?Patient had mentioned a sore throat

Why?Patient had an endoscopy 3 days ago and hasn’t been

drinking water at bedside or meals. Throat pain caused by procedure that staff were

not aware of; were unaware of degree of discomfort for the patient.

The 5 Why Approach


Mr. Brown’s dehydration:Throat pain caused by procedure that staff

were not aware of; were unaware of degree of discomfort for the patient.

Why was staff unaware of the procedure?

The physician’s note and follow-up instructions were not received.

Why? No standard process with clinics for information/follow-up after appointments.

Commonly Discovered Root Causes

Communication breakdowns:

• Missed signs of resident condition changes• Staff respond to clinical situations differently• Handoff problems with other organizations• INTERACT Tools not consistently used


Prioritizing Findings

• Come to a group consensus on the top 2 or 3 things that could be improved based on your Root Cause Analysis

• Update your QAPI Goal Setting Worksheet


QAPI

• Use QAPI Toolkit for your performance improvement plan

• Revisit your Goal Setting Worksheet to update your plan based on your finding from the Root Cause Analysis


Communication breakdowns SBAR

Missed signs of resident condition changes Stop and Watch Tool

Staff respond to clinical situations differently Care Pathways

Handoff problems with other organizations Transfer Tools


How INTERACT Links to Root Causes

What?

Who?

When?

How?


Make a Plan to Do the Improvements

What will you do for action steps?

Who will do the work? Who should be involved?

When should steps be completed by?

How will you make progress?How will you know progress is on track?

“How is it Going” Checklist

Are you meeting as a team? Is data being gathered and submitted in a

timely way? Have you agreed upon clear next steps Have you connected with other staff to

participate in the effort? Are you updating your QAPI Goals

Worksheet?


Recommended Action Items


Root Cause Analysis Action Items1. Determine who is involved in tracking transfers; check on data submission2. Review 3-5 Acute Care Transfers with the team; use QI Tool and determine root causes3. Modify your QAPI Goal Setting Worksheet (your PIP) and develop a plan4. Submit data

Online Resources


Recorded Webinars available on:Wisconsin Clinical Resource Centerhttps://wcrc.chsra.wisc.edu (Requires your WCRC Username and Password)WHA Quality Centerhttp://www.whaqualitycenter.org/LearningOpportunities/INTERACTwithQAPI.aspx

Other resources:INTERACT Websitehttp://interact2.net/MetaStar QAPI Resourceshttp://www.metastar.com/web/Default.aspx?tabid=573Advancing Excellence – Safely Reduce Hospitalizations Tracking Tool (Data spreadsheet)http://www.nhqualitycampaign.org/star_index.aspx?controls=hospitalizationsidentifybaseline

References


Attendance Verification for Credits

Full SERIES attendance (four webinars) and Evaluation: Copy and enter into your web browser:

http://www.surveymonkey.com/s/Interact10-30-13 Social Workers – post-test required (is part of eval) Everyone please complete the online evaluation – thank you!

Contact Information:


Jody Rothe, RN, WCCQuality Consultant

MetaStar, Inc.2909 Landmark PlaceMadison, WI 53713

Phone number: (608) 441-8271 or (800) 362-2320

www.metastar.com

[email protected]

Documents

INTERACT with QAPI