presented by Sue Ann Guildermann
This course is part 1 of a 4-part series of the Empira Falls Series. Empira is a consortium of Aging Service providers in Minnesota who created a successful falls program in the nursing home setting based on Root Cause Analysis (RCA) and evidence-based research. This course provides all staff in nursing homes with the key concepts, methodology and tools of RCA to assist in determining causation of problems, conditions and situations. RCA is a structured method of problem solving utilized to find out what happened and why it happened, and to determine what can be done to prevent it from happening again. While it is frequently used when something goes wrong, RCA can also be used when something goes right – to ensure that it happens again. Focusing performance improvement operations at root causes is more effective than merely treating the symptoms of problems.
Sue Ann Guildermann has over forty years experience providing education, leadership and consultation to non-profit and for-profit senior service organizations. Sue Ann is a Registered Nurse with a BA and MA in communication. She currently conducts research of evidence-based findings and practices to create quality improvement programs, educational seminars and conferences with targeted solutions for Empira, a consortium of 26 skilled nursing facilities and 14 Assisted Living facilities in Minnesota. For the past three years she has traveled nationally to share the findings from the work of two national and state quality improvement grants awarded to Empira. The purpose of these grants was to reduce resident falls in skilled nursing homes and to ensure that their residents slept undisturbed throughout the night.
Root Cause Analysis (RCA) is a structured process to identify causation by exploring what, how, and why something happened. The ability to select appropriate solutions occurs when causation has been identified. Aligning solutions with causation results in predictable outcomes with near-certain prevention of recurrences.
The concept of RCA will be introduced and applied to clinical conditions with intervening solutions. Optimal health care is achieved when RCA is used to determine the cause of clinical conditions.