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RISK MANAGEMENT:

Outcomes Not Improving? Get in a New QA Groove

Published on Sun Feb 15, 2009

Master the simple inside secret to implementing lasting changes.

If your quality assurance team seems to be fixing the same problems over and over, it might be time to get off the treadmill.

A better plan: Use a root-cause analysis approach where the team keeps asking, "why" to reveal the likely cause(s) of a problem. "Root cause analysis allows you to really resolve an issue more quickly -- it's a way of thinking," says Sue LaBelle, MSN, RN, RAC-CT, who presented on quality improvement at the fall 2008 annual American Health Care Association meeting in Nashville, Tenn. "If you don't address the root cause, the problem will crop up again," cautions Sheila G. Capitosti, RN-BC, NHA, MHSA, who co-presented with LaBelle.

Of course, using RCA isn't new. But seeing the process in action can be eye-opening in terms of how it can lead to simple, targeted solutions to persistent problems.

For example, if the facility has a significant number of residents with pressure ulcers, ask why the facility has them, advises LaBelle. If the pressure ulcers occurred in-house, why are the residents developing them? "The answer might be that they aren't moving around in the bed enough," she says. "If so, why? There aren't enough turning and repositioning programs implemented. Why? Is staff missing people at risk in terms of needing individualized turning and repositioning? You may find out that the assessment isn't working because it doesn't identify the risk," LaBelle continues. Or the assessment tool may have identified the risk, but staff doesn't fill it out completely or they need education to learn how to do the assessment, LaBelle tells Eli.

Another example: Suppose a resident develops pressure ulcers on the night shift and you can identify the CNAs who didn't turn the person as directed, says Rena Shephard,MHA, RN, RAC-MT, C-NE, president and CEO of RRS Healthcare Consulting Inc. in San Diego, and founding chair and executive editor of the American Association of Nurse Assessment Coordinators.

"You can stop there or, more effectively, look at the entire resident care system of which the CNAs are a part," she suggests. And ask how many patients each of the CNAs has on the night shift. "The answer can easily be 15 to 20 residents per nursing aide, and 10 of those residents or more may require frequent repositioning," Shephard notes. If that's the case, "the job is just not doable."And the facility may need to provide adequate resources, she adds.

It takes 2 to tangle: Does your facility have resident-to-resident altercations? Ask why the resident(s) became aggressive -- and why the victim of the aggression became a target, LaBelle suggests. "Sometimes you find that residents who are victims of [resident aggression] inadvertently trigger the aggression; for example, wanderers may go into other residents' rooms and put themselves in harm's way," she notes.

"[And] if you just focus on the aggressor, you are looking at only part of the problem and may miss the whole picture," LaBelle cautions.

Drill Down in Analyzing QIs/QMs

Sometimes facilities "react to the numbers on their QI/QMs and then identify what they think is the cause without really investigating or doing an RCA," cautions Capitosti.

Case in point: One facility attributed its high prevalence of pressure ulcers to the fact that it admitted so many residents with pressure ulcers, says Capitosti. But in applying RCA, the facility found that some of the pressure ulcers present at admission had worsened.

Implement, Evaluate, Monitor

Once you identify the cause of a problem, design an intervention to address it. "Sometimes people implement more than one thing at a time and can't identify whether something was effective," cautions Capitosti. If an intervention works, maintain it."If not, you identify another intervention to help or further improve the process."

Don't stop short: Monitor to make sure the intervention continues to work. For example, you may stabilize staff as an intervention to reduce pressure ulcer rates on a unit. But then staff begins to turn over again at some point. And the reason for the turnover may be different than previously, says Capitosti.

Get All Levels of Staff With the RCA Program

Expand your QA subcommittees to address specific problems, such as falls or pressure ulcers, suggests Capitosti. "Educate people on that subcommittee on how to do rootcause analysis and then reward them for successes," she advises.

"Create career leaders where those initial subcommittee members become trainers to train future subcommittees." You can do this at any level -- "for example, involve the CNAs and dietary departments related to nutritional issues."

Share the risk management: Let the QA subcommittees chronicle their successes by using story boards, suggests Capitosti. Then post the storyboards in employee, resident, and public areas in the facility. "It can be very creative," she adds.

You can also enlist residents/families in quality improvement, Capitosti suggests. "Many people fear doing that due to our litigious society, but evidence shows that if you involve residents/families, they are less likely to sue."

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