Aggregate Root Cause Analysis: Effective Interventions and Implementation Strategies to Reduce Falls and Related Injuries in the VA System

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Damon Griffith
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1 Aggregate Root Cause Analysis: Effective Interventions and Implementation Strategies to Reduce Falls and Related Injuries in the VA System Peter D. Mills Ph.D., M.S.; Julia Neily RN, M.S.; Erik Stalhandske, M.P.P., M.H.S.A.; Diana M. Luan, RN, MPA, MS; William B. Weeks MD, MBA, CHE Field Office of VA s National Center for Patient Safety, White River Junction, Vermont, Veterans Health Administration; Veterans Affairs National Quality Scholars Fellowship Program, Veterans Health Administration; Dartmouth Medical School, Hanover, New Hampshire, USA Key Contact Julia.Neily@Med.VA.Gov Background: Falls among elderly are common, costly, dangerous, and often preventable. Approximately one-third of adults over 65 years old are reported to fall each year. Those living in institutions fall three times that rate (1.5 falls per bed per year), with as many as 25 percent of institutional falls resulting in fracture, laceration or need for hospital care. 1-4 One method of determining causes of falls is Root Cause Analysis (RCA)(5, 6). Aggregate root cause analyses (7) examine multiple falls for a specific time period. Purpose of the Study: This descriptive study examined aggregate fall RCA s from 97 Veterans Health Administration (VHA) facilities that were submitted during the first six months of the program initiation and during the pilot phase of the program (time span of October 1999 to June 2002). The purpose was to study relationships between actions and reported reductions in fall and related injuries. These findings may be useful to those implementing fall prevention programs.

Weeks MD, MBA, CHE Field Office of VA s National Center for Patient Safety, White River Junction, Vermont, Veterans Health Administration; Veterans Affairs National Quality Scholars Fellowship

2 Methods: Two members of the research team coded the 176 RCA s and two other members of the research team interviewed sites about action implementation. We entered results of interviews and coding of the root cause analyses into a database. We then examined the relationships between actions and outcomes. For example we examined if sites that implemented toileting programs also reported reductions in fall rates or major injuries. We reported descriptive statistics for root causes and actions; as well as aids and barriers to implementing actions. We analyzed the relationship between implemented actions and reported reductions in falls or major injuries, using non-parametric correlation analysis (Spearman s rho); and analyzed relationships between reported reductions in falls and major injuries, and the use of outcome measures and implementation strategies. Fall rates and reductions in major injuries were by self-report. Results: The RCA S aggregated 10,701 falls producing 17 types of root causes and 27 types of actions. 435 (61.4%) of the 745 actions had been implemented and 148 (20.9%) partially implemented. Forty four percent of root causes were policy or procedure problems, 23% communication problems, 16% more training, 13% environmental causes and 4% fatigue or scheduling problems. (Figure 1) More specific root-cause categories reported are displayed in Figure 2. We analyzed each action to see whether it addressed the root cause it was suppose to address and found that 95% (708) of the actions did, in fact, address the root cause. Using the RCA Team to implement change was associated with improved implementation, while neglecting to get staff feedback before implementing change, and lack of time and resources to implement change were barriers. 34.4% reported reducing falls and 38.9% reported reducing major injuries due to falls; (figure 3) and actions associated with these

For example we examined if sites that implemented toileting programs also reported reductions in fall rates or major injuries.

3 reductions were focused on making specific clinical changes, rather than policy changes or educating staff. Interventions associated with improved clinical outcomes included environmental assessments (r =.121, p =.012), toileting interventions; (falls, r=.102, p=.033) (major injuries r =.124, p =.010), interventions that addressed the root cause, (r =.094, p =.010) and actions that were the responsibility of a single person (as opposed to a group) (r =.10, p =.006). Participation in a Collaborative Breakthrough Series on reducing falls and injuries due to falls was correlated with reported reductions in falls (r =.217, p = 0.33) and major injuries (r =.335, p =.001). Conclusions and Implications: Actions focused on clinical changes are more effective than policy changes or staff education. Using RCA teams to implement changes, giving an individual responsibility for implementing actions, getting staff feedback before implementing changes, and giving change teams time and resources can increase chances of implementation. Using implementation alone is not a good measure of improved clinical outcomes; it is important to measure actual changes in clinical outcomes. Lastly, participation in the Falls Breakthrough Series appears to have helped facilities reduce falls and injuries due to falls. References: 1. Rubenstein L, Josephson K, Robbins A. Falls in the Nursing Home. Annals of Internal Medicine 1994; 121: Doweiko D. Prevention Program Cut Patient Falls by 10%. Hospital Case Management 2000; 8:38,

010), interventions that addressed the root cause, (r =.094, p =.010) and actions that were the responsibility of a single person (as opposed to a group) (r =.10, p =.006).

4 3. Rubenstein L, Powers C, MacLean C. Quality Indicators for the Management and Prevention of Falls and Mobility Problems in Vulnerable Elders. Annals of Internal Medicine 2001; 135: Hoskin A. Fatal Falls: Trends and Characteristics. Statistical Bulletin 1998; 79: Joint Commission on Accreditation of Healthcare Organizations: 2003 Comprehensive Accreditation Manual For Hospitals: The Official Handbook. Oakbrook Terrace, IL: Joint Commission Resources, Inc, Wald, H, and Shojania KG. Root Cause Analysis. In: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Agency for Healthcare Research and Quality, p Neily, J., Ogrinc, G., Mills, PD, Williams R., Stalhandske, E., Bagian, J. and Weeks WB. (2003). Aggregate Root Cause Analysis: An Effective Process to Improve Patient Safety. The Joint Commission Journal on Quality and Safety. V.29,

Joint Commission on Accreditation of Healthcare Organizations: 2003 Comprehensive Accreditation Manual For Hospitals: The Official Handbook.

5 Figure 1: General categories of root causes identified in falls aggregate reviews: Problems w ith Polices/Procedures Communication Problems Need for more Training Environmental Causes Fatigue or Scheduling Problems 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Communication Problems Need for more Training Environmental

6 Figure 2: Specific root causes listed for falls. (T) = Training, (P)= Policy/Procedures, (C) = Communication, (E) = Environmental, (F) = Fatigue/Scheduling. Staff needs more training (T) Lack of a specific intervention for a specific patient population (P) Current system for falls assessment needs improvement (P) Documentation quality needs improvement ( C) Communication of fall risk needs improvement ( C) Lack of equipment increases the likelihood of a fall (E) Lack of current system for falls assessment (P) Environmental problems - not otherwise specified (E) Medical record needs improvement ( C) Problem with communication - not otherwise specified ( C) Fatigue/Scheduling Problems (F) Problem with policy - not otherwise specified (P) Environmental problems increase the likelihood of a fall (E) Current system for falls intervention need improvement (P) No current system for falls intervention (P) Falls Intervention not being done (P) Falls assessment not being done (P) 0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

C) Communication of fall risk needs improvement ( C) Lack of equipment increases the likelihood of a fall (E) Lack of current system for falls assessment (P) Environmental problems - not otherwise

7 Figure 2: Reports of reductions in falls and major injuries due to falls: Reduction in Falls Not measuring Too soon to tell Measuring and the same Measuring and improved Reduction in Major Injuries Not measuring Too soon to tell Measuring and the same Measuring and improved 0% 10% 20% 30% 40% 50%

Measuring and improved Reduction in Major Injuries Not measuring Too soon

Title: uthor: Background Knowledge: Local Problem: Intended Improvement:

Title: uthor: Background Knowledge: Local Problem: Intended Improvement: 1. Title: The Use of a Cognitive Aid within the Electronic Record can greatly improve the effectiveness of communication among care givers and reduce patient injuries from falls. 2. Author: M. Kathleen