During our first Action Period support call, attending nursing home teams shared success stories from their experiences using root-cause analysis (RCA) and plan-do-study-act (PDSA) cycles. Among the accomplishments:
Bethany at Silver Lake used the Fishbone diagram tool to determine that a pattern of falls was related to toileting after transfers from the hospital.
Columbia Lutheran Home used a PIP Prioritization process and the 5 Whys RCA tool to help them focus work on their bowel and bladder retraining program. After three PDSA cycles, they found that what worked best was providing positive reinforcement to the staff for correctly documenting voiding patterns in their EHR.
Sequim Health & Rehabilitation Center identified an opportunity to improve staff satisfaction by soliciting and sharing feedback. They hosted a “Feed for Feedback” meal where staff completed a survey to get a ticket to the event. The administration began a new pattern of intentional rounding to share specific positive feedback, thanking staff, etc. They plan to have another “Feed for Feedback” event in a few months to measure the effect of this change.
At Stafford Healthcare at Ridgemont, a staff nurse initiated a test of walking rounds for shift report that included visiting with each resident to include them in the report. After this PDSA, she provided feedback in a list of pros and cons. The nurse was so excited about the improvement and the time saved that she is now championing the best practice to help spread it to other units and shifts.