Long-Term Care Survey Alert
Maintain This Key Refrain When Doing Root-Cause Analysis
Keep digging to ferret out the problems.
Some facilities feel daunted by the time that root-cause analysis requires or they view the process as too highfalutin. But "you can simplify a root-cause analysis," says Edythe Cassel Walters, MBA, RN, NHA. "It's doesn't have to take 60 hours to do."
Just keep asking, Why did this happen? For example, Why did the resident fall? Suppose your first answer turns out to be: "The nurse aide caring for him didn't use a two-person assist," as required, says Walters, director of LW Consulting in Harrisburg, PA.
The next question: Why? The facility was short-staffed on the day shift again. Why was it short-staffed? A couple of staff people keep calling in sick. Next question: Has anyone asked or addressed why they keep calling in sick?
Another trail of why's: The resident fell because the CNA didn't use a two-person assist, as the care plan directed. Why? The CNA didn't know what the care plan required. Why? The facility doesn't have a reliable way to keep CNAs up to date with care plan interventions. In addition, CNAs don't regularly care for the same residents.
"When errors occur, 95 percent of the time it's due to a problem with the process--not the person" who made the mistake, says Cindy Oehmigen, a process improvement consultant in Syracuse, NY.
"When you have a stressful process, there are measures you can put in place to help mistake-proof the process," she adds.
What about bad apples? "If the facility has people on board whose performance is consistently not up to par--or who haven't responded to additional inservicing and counseling, etc.--then the process for ensuring quality staffing isn't working," concludes Oehmigen.
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