Root Cause Analysis – Assisted Living
Frieda Pulkowski, RN, BSN, NHA, MS
Proactive versus reactive living
Why?
Performance improvement
Clinical versus non clinical indicators
What else…
Why?
Selection and characteristics of performance measures/incidents and events to analyze
How?
A word about data collection…
Ask the housekeeper AKA “You can’t handle the truth”
How?
Determining the root cause(s)
Is it controllable and fixable or not
How?
Caution….
Correlation versus
Causation versus
Coincidence
And….what about computers?!
How?
Types of RCA
The 5 Whys
Fishbone/Ishikawa Diagram
Narrative Sequencing of Events
Others
How?
Plan and develop – typical approaches are:
Your method
Failure mode and effects
Impact analysis
Kaizen
Others
Next Steps