Copyright 2013-2014 Direct Supply, Inc. All rights reserved

RCA Summary Outline (Ray Miller 414 405 0492; rmiller@directs.com)Program Overview

Why Root Cause Analysis (RCA): QAPI -- Element 5: Systematic Analysis and Systemic Action

The facility… uses a systematic approach:

1. To fully understand the problem, its causes, and implications of a change.

2. To determine … how identified problems may be caused or exacerbated by the way care

and services are organized or delivered.

3. The facility will … demonstrate proficiency in the use of RCA … to prevent future

events AND promote sustained improvement.

RCA Reality Check: It is worth noting that RCA is identified by CMS as one of the Greatest QAPI Challenges

Breaking out of silos of disciplines, departments, & shifts to work system-wide

Using data systematically to get a comprehensive overview of performance

Building in systematic resident and family input without bias

Using “systems thinking” in all quality efforts

Turning data into meaningful information

Applying root cause analysis

Structuring PIPs.

But you have always sought to adopt best practices to better achieve QUALITY of Care and

QUALITY of Life. RCA is one of those best practices.

Where does RCA fit? In the simple image below, what might be thought of as a nursing investigative process, RCA is

one of the investigative tools that should be employed.

The numbered steps can be thought of in these ways:

1. Identify and describe the issue / incident / problem

2. Investigate and gather data

3. Analyze data and fill in the gaps

4. Formulate and test the proposed interventions

(Prospective RCA – ask your “5 WHY’s about what

could happen as a result to the proposed changes.)

Of course you would then “Implement” and

“Monitor/Modify”.

Cause Mapping - Root Cause Analysis (Post-acute Care) Prevention, by improving work processes (NO blame)

What Description

When Date

Time

Different, unusual

Where Facility Name

Location

Care / Work Process

Categories Clinical Resident Choice Organizational Infrastructure

Specific Medications Mobility Hospitalizations

Goals Mobility Bathing Staff Stability

Infections Person-centered care Consistent Assignment

Pressure Ulcers Person-centered care

Pain Management

Goal Category Specific Goal

Owner Cause Intervention/Solution Due Date

Copyright 2013-2014 Direct Supply, Inc. All rights reserved

Impact to Goals

Step 1. Problem Outline

Step 3. RCA and Cause Mapping ("The Weed" and "Post-It Note Analysis" )

Step 4. Interventions/Solutions

Frequency:

Step 2. List the Category and Specific Goals and Identify Impacts to Those Goals

Goal Impacted

Relative to the Advancing Excellence in America’s Nursing Homes campaign, the Circle of

Success also includes RCA and an integral part of the process.

Circle of Success

What are the steps of RCA? (Prevention, by improving work processes [NO blame]) Step 1. Problem Outline:

What: Description:

When: Date:

Time:

Different OR Unusual:

Where: Facility Name:

Location:

Care/Work Process:

Step 2. Identify and list the Goal Categories, Specific Goals, Impacts to Those Goals of the

incident and the frequency of occurrence

a. Goal Categories: Clinical Resident Choice Organizational Infrastructure

b. Specific Goals: Medications Mobility Hospitalizations

Mobility Bathing Staff Stability

Infections Person-centered Consistent Assignment

Pressure Ulcers Person-centered care

Pain Management

c. List actual Goal Category/ies, the Specific Goal & the impact of the incident to the goals

d. Frequency:

Step 3. "The Weed" and "Post-It Note Analysis"

a. The Weed – RootS Cause Analysis

Start by being sure that the incident is

accurately defined. Then start asking

“WHY” using the categories listed on

the image: People, P&P, Education,

Clinical/Medical, Equipment,

Environment and Management.

a. “Post It Note Analysis”: Use the post-it notes to list the steps and events in the process as

your interdisciplinary team brain storms the event always asking “WHY”. Then start

ordering the post-it notes looking for casual relationships and best points for the

intervention/interventions.

Step 4. Interventions/Solutions: Develop (and test) the interventions being sure to list the Owner,

the Cause of the incident, the Intervention/Solution and the Due Date.

Copyright 2013-2014 Direct Supply, Inc. All rights reserved

Sustaining Quality: Making Root Cause

Analysis Practical and Productive

We will begin at

9 AM Ray Miller, MSOSH, GP

Dir. Risk/Safety Solutions

1

Ray Miller, BS, MSOSH, GP Direct Supply Dir. of Risk & Safety Solutions

> Has 33+ years in HC safety/risk (28+ years in post-acute care)

> Is a former corporate safety director for several LTC companies

> Has devoted his career to the development of HC risk and

safety strategies, programs and solutions

> Serves on the AHCA Emergency / Disaster Prep. Committee

> Is a founding member of the Direct Supply-sponsored Loss

Prevention Forum

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 2

Disclaimer

The materials, comments and other information

contained in this presentation are intended to provide

general information but not advice about certain

regulations and initiatives.

This information is not and not intended as legal or

other advice and each situation may vary depending

on the particular facts and circumstances.

You should not act upon this information without first

consulting with qualified legal counsel.

Thank You.

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 3

Agenda

1. OPENING: Introduction + Examples + Systems

2. HISTORY: Your Personal Pursuit of Quality + HATChTM

3. DEFINITIONS and COMPARISONS:

a. Nursing Process and Circle of Success

b. Near Miss (vs. Near Hit) Analysis

c. Root Cause Analysis and Cause Mapping

d. QA and Attorney Client Privilege

4. DEMONSTRATION: Root Cause Analysis

5. APPLY: VIDEO CLIP

6. GROUP PRACTICE

7. CHANGE MANAGEMENT (“Never Events” vs. “Always Events”)

8. Q&A: ATP (As Time Permits)

4 Copyright 2014-2015 Direct Supply, Inc. All rights reserved 4

Agenda

1. OPENING: Introduction + Examples + Systems

2. HISTORY: Your Personal Pursuit of Quality + HATChTM

3. DEFINITIONS and COMPARISONS:

a. Nursing Process and Circle of Success

b. Near Miss (vs. Near Hit) Analysis

c. Root Cause Analysis and Cause Mapping

d. QA and Attorney Client Privilege

4. DEMONSTRATION: Root Cause Analysis

5. APPLY: VIDEO CLIP

6. GROUP PRACTICE

7. CHANGE MANAGEMENT (“Never Events” vs. “Always Events”)

8. Q&A: ATP (As Time Permits)

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 5

Reasons For Attending This Session

WHAT:

“Learn” how to “do”, “document” and “teach” Root Cause

Analysis (RCA)

SO WHAT:

Protect your Residents and Staff from injuries by applying

RCA (Root Cause Analysis)

NOW WHAT:

Acquire, Understand, Apply

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 4 6

SIDEBAR: David O. McKay, 1969

"Words do not convey meanings; they call them forth.

I speak out of the context of my experience. You

listen out of the context of yours. And that is why

communication is difficult."

Defining My

Understanding

7 Copyright 2014-2015 Direct Supply, Inc. All rights reserved

8

Wordle.net

US: L e a d e r s h i p

Issue/Problem Goals Causes Solutions/Interventions

1. ISSUE:

Broken

Glasses

2. GOALS:

Nothing Broken

Quick Cleanup

No Arguments

3. CAUSES*:

Too much

Communication

Pantry Door

Ceramic Floor

Beth / Jason

4. SOLUTIONS:

Guest Clean-up

Plastic Cups

Use a Tray

Carpeted Floor

Re-Hang Door

Communicate

Personal Development

* Assessments, Investigations, Interviews, Analysis Copyright 2014-2015 Direct Supply, Inc. All rights reserved 9

Heyókȟa

Refers to the Lakota concept of a contrarian

Please, be willing to change …

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 10

Personal Example

http://girbauindustrial.com/open-pocket/open-pocket-dryers.html

1. Heated air

2. Cool 98⁰ water

3. Insufficient chemicals

4. Over loaded washers

5. Cloth / soiled diapers

6. 67% isopropyl alcohol

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 11

Albert Einstein:

"Any intelligent fool can make things bigger

(and) more complex ...

It takes a touch of genius

and a lot of courage

to move in the opposite direction."

Systems and Efficiencies

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 12

How does this apply to

Root Cause Analysis?

Agenda

1. OPENING: Introduction + Examples + Systems

2. HISTORY: Your Personal Pursuit of Quality + HATChTM

3. DEFINITIONS and COMPARISONS:

a. Nursing Process and Circle of Success

b. Near Miss (vs. Near Hit) Analysis

c. Root Cause Analysis and Cause Mapping

d. QA and Attorney Client Privilege

4. DEMONSTRATION: Root Cause Analysis

5. APPLY: VIDEO CLIP

6. GROUP PRACTICE

7. CHANGE MANAGEMENT (“Never Events” vs. “Always Events”)

8. Q&A: ATP (As Time Permits)

11 Copyright 2014-2015 Direct Supply, Inc. All rights reserved 14

Efforts For Quality

Kaizen (Japanese term that refers to activities that continually

improve ALL functions involving EVERYONE)

ZD (Zero Defects)

QC (Quality Circles)

A3 Cause Mapping

SPC (Statistical Process Control)

TQM (Total Quality Management)

PRIDE (Professional Results In Daily Efforts)

CQI (Cycle of Continuous Quality Improvement)

QAPI (Quality Assurance Performance Improvement)

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 15

“How many of you are

already using …

RCA to get to the heart

of … a problem?”

(12 Elements)

Element 5: Systematic Analysis and Systemic Action

The facility… uses a systematic approach:

1. To fully understand the problem, its causes, and implications of a

change.

2. To determine … how identified problems may be caused or exacerbated

by the way care and services are organized or delivered.

3. The facility will … demonstrate proficiency in the use of RCA … to

prevent future events AND promote sustained improvement.

Element 11: Getting to the Root of the Problem

“Use the RCA process to look at the system rather than individuals

when something breaks down”

Why are we

talking about

“RCA”?

16

What is RCA?

A process to figure out:

1. What happened

2. Why did it happened

3. How to prevent it from happening again

4. OR, to prevent it from happening the 1st time

When have YOU used RCA?

17 Copyright 2014-2015 Direct Supply, Inc. All rights reserved

SIDEBAR: Ishikawa / Fishbone-ing

Equipment

Issu

e /

Op

po

rtun

ity

Education Environment

P&P People, Staff, HR

Management

18 Copyright 2014-2015 Direct Supply, Inc. All rights reserved

Change to Contracted Laundry Services – Asking “WHY”

People, Hiring, HR

1.

P&P

1.

Education

1.

Clinical, Medical

1.

Equipment

1.

Environmental

1.

Management

1.

Retro

sp

ectiv

e v

s. P

rosp

ectiv

e R

CA

19 Copyright 2014-2015 Direct Supply, Inc. All rights reserved

Change to Contracted Laundry Services – Asking “WHY”

People, Hiring, HR

1. Payroll

2. Schedule

3. TB / Criminal / Drug

P&P

1. Infection Control

2. HIPAA

3. Lost Laundry

4. Hallway Management

Education

1. Not our necessarily

our responsibility BUT

still our concern

Clinical, Medical

1. Allergies

2. Prior experiences

Equipment

1. Care

2. Expenses

3. Maintenance

Environmental

1. Spills

2. Waste

3. Chemicals

4. Staff Smoking

Management

1. ROI

2. Staffing

3. Survey issues

4. Personal Laundry

5. Monitoring outcomes

Re

tros

pe

ctiv

e v

s. P

ros

pe

ctiv

e R

CA

20 Copyright 2014-2015 Direct Supply, Inc. All rights reserved

REVIEW: Proactive vs. Reactive

Prospective – “before”

Speculate

Predict

Prior

Retrospective – “after”

Investigate

Collect

Study

21 Copyright 2014-2015 Direct Supply, Inc. All rights reserved

Greatest Challenges

• Breaking out of silos (disciplines, departments, shifts)

• Using data systematically (comprehensive overview)

• Consistently seeking resident and family input

• Using “systems thinking” in all quality efforts

• Turning data into meaningful information

• Applying root cause analysis

• Structuring PIPs

* 1. Quality Always Matters (Care / Life)

2. RCA = A GOOD tool & Best Practice

22 Copyright 2014-2015 Direct Supply, Inc. All rights reserved

Greatest Challenges

• Breaking out of silos of disciplines, departments

and shifts to work system-wide

• Using data systematically to get a comprehensive

overview of performance

• Building in systematic resident and family input

without bias

• Using “systems thinking” in all quality efforts

• Turning data into meaningful information

• Applying root cause analysis

• Structuring PIPs.

* 1. Quality Always Matters (Care / Life)

2. RCA = A GOOD tool & Best Practice

23 Copyright 2014-2015 Direct Supply, Inc. All rights reserved

The HATChTM Model

Holistic Approach

to Transformational ChangeTM

On 9 Dec 2014 Kara Butler of Healthcentric Advisors granted

Direct Supply permission to use the HATChTM

Model.

Ray Miller

Direct Supply

Dir. of Risk

and Safety Solutions

Healthcentric Advisors (QIO)

235 Promenade Street, Suite 500, Box 18

Providence, RI 02908

401-528-3221 or

kbutler@healthcentricadvisors.org.

http://www.healthcentricadvisors.org/

http://vimeo.com/57899184

R

3. Environment

Clinical

Practice

1-Body

2-Mind

3-Emotions

Work Place

Practices

1-Do

2-Hire

3-Train

4-Mentor

5-Retain

Environment

1-Five Senses

2-Safety

3-Comfort

4-Cleanliness

5-Compassion Key

Responsibilities

25

R

3. Environment

Leadership

1-Vision

2-Team

3-Culture*

4-Finance

5-Processes

6-Education

7-Development

8-Human Rsrcs.

9-Physical Plant

CULTURE*

1-Trust

2-Quality

3-Patience

4-Sanctuary

5-Friendship

6-Fulfilment

7-Engagement

Key

Responsibilities 26

R

3. Environment

Community

and Family

1-HOME

2-Society

3-Connection

4-Engagement (RSF)

5-

6-

Compliance

1-Knowledege

2-Awareness

3-Experience

4-Preparation

5-Consistency Key

Responsibilities

27

27

R

3. Environment

Holistic

Approach to

Transformational

ChangeTM

The HATChTM

Model

28

28

Work Place

Practice

1-Do

2-Hire

3-Train

4-Mentor

5-Retain

Environment

1-Five Senses

2-Safety

3-Comfort

4-Cleanliness

5-Compassion

Leadership

1-Vision

2-Team

3-Culture*

4-Finance

5-Processes

6-Education

7-Development

8-Human Rsrcs.

9-Physical Plant

CULTURE* 1-Trust

2-Quality

3-Patience

4-Sanctuary

5-Friendship

6-Fulfilment

7-Engagement

Community

and Family

1-HOME

2-Society

3-Connection

4-Engagment

5-

6-

Compliance

1-Knowledege

2-Awareness

3-Experience

4-Preparation

5-Consistency

Which domains can

you focus on when

developing

interventions?

Clinical

Practice

1-Body

2-Mind

3-Emotions

*

* *

29

Agenda

1. OPENING: Introduction + Examples + Systems

2. HISTORY: Your Personal Pursuit of Quality + HATChTM

3. DEFINITIONS and COMPARISONS:

a. Nursing Process and Circle of Success

b. Near Miss (vs. Near Hit) Analysis

c. Root Cause Analysis and Cause Mapping

d. QA and Attorney Client Privilege

4. DEMONSTRATION: Root Cause Analysis

5. APPLY: VIDEO CLIP

6. GROUP PRACTICE

7. CHANGE MANAGEMENT (“Never Events” vs. “Always Events”)

8. Q&A: ATP (As Time Permits)

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 30

Nursing Process and RCA

3a

3b

4

1, 2

31

It’s worth

the time

1. Issue

2. Goals

3. Causes

4. Interventions

Copyright 2014-2015 Direct Supply, Inc. All rights reserved

Circle of Success

Plan Do

Study

(RCA)

Act

*

1. Issue

2. Goals

3. Causes

4. Interventions

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 32

Agenda

1. OPENING: Introduction + Examples + Systems

2. HISTORY: Your Personal Pursuit of Quality + HATChTM

3. DEFINITIONS and COMPARISONS:

a. Nursing Process and Circle of Success

b. Near Miss (vs. Near Hit) Analysis

c. Root Cause Analysis and Cause Mapping

d. QA and Attorney Client Privilege

4. DEMONSTRATION: Root Cause Analysis

5. APPLY: VIDEO CLIP

6. GROUP PRACTICE

7. CHANGE MANAGEMENT (“Never Events” vs. “Always Events”)

8. Q&A: ATP (As Time Permits)

11 Copyright 2014-2015 Direct Supply, Inc. All rights reserved 33

Data/Analysis Challenges -- Near-Miss Analysis

The Mishap Reporting Pyramid

Severity

Frequency

34

The Mishap Occurrence Pyramid

Severity

Frequency Frequency

Data/Analysis Challenges -- Near-Miss Analysis

35

36

http://www.thinkreliability.com/pdf/AvoidingTitanicProblems-Summary.pdf

St. Joseph Medical Center (Il):

Enabled informal reporting of errors and

near-misses among nursing staff

□ Holding safety briefings at shift changes (What did you see?)

□ Implementing "walk rounds" by hospital's executives

□ Instituting a telephone hotline to simplify reporting

adverse drug events

This resulted in a 91% drop in the rate of adverse

drug events. Stories from the Sharp End:Case Studies in Safety Improvement Authors: Douglas McCarthy, M.B.A., and

David Blumenthal, M.D.Summary Writer(s): Linda Prager and Deborah Lorber March 27, 2006 | Volume 34

Data/Analysis Challenges -- Near-Miss Analysis

37

Near-Misses:

“Trivial events in non-trivial systems should not go unremarked.” Perrow, 1984

Thought to be the immediate precursors of

possible adverse events

Many times, employee choices and actions

make the essential difference between harm

and no harm … (between an emergency and a disaster)

So, how can we use it?

Near-Miss Analysis

38

Agenda

1. OPENING: Introduction + Examples + Systems

2. HISTORY: Your Personal Pursuit of Quality + HATChTM

3. DEFINITIONS and COMPARISONS:

a. Nursing Process and Circle of Success

b. Near Miss (vs. Near Hit) Analysis

c. Root Cause Analysis and Cause Mapping

d. QA and Attorney Client Privilege

4. DEMONSTRATION: Root Cause Analysis

5. APPLY: VIDEO CLIP

6. GROUP PRACTICE

7. CHANGE MANAGEMENT (“Never Events” vs. “Always Events”)

8. Q&A: ATP (As Time Permits)

11 Copyright 2014-2015 Direct Supply, Inc. All rights reserved 39

Agenda

1. OPENING: Introduction + Examples

2. HISTORY: Your Personal Pursuit of Quality

3. DEFINITIONS and COMPARISONS:

a. Nursing Process and Circle of Success

b. Near Miss (vs. Near Hit) Analysis

c. Root Cause Analysis and Cause Mapping

d. QA and Attorney Client Privilege

4. PRACTICE: Root Cause Analysis

5. APPLY: VIDEO CLIP

6. GROUP PRACTICE

7. Q&A: ATP (As Time Permits)

11 Copyright 2014-2015 Direct Supply, Inc. All rights reserved 40

Used with permission from: ThinkReliability 41 Copyright 2014-2015 Direct Supply, Inc. All rights reserved

People, Hiring, HR

1.

P&P

1.

Education

1.

Clinical, Medical

1.

Equipment

1.

Environmental

1.

Management

1.

Which of these can you personally ask AND

answer “why” 5 times?

WHO else would you engage?

Copyright 2014-2015 Direct Supply, Inc. All rights reserved

What are some examples of when you can or

should use RCA ?

42

Goal

Impacted Effect

Cause /

Effect

Cause /

Effect

Cause /

Effect

Effect /

Cause

Effect /

Cause

Solution / Intervention

Solution / Intervention

Solution / Intervention

(Issue is Defined)

Goal

Impacted

Cause Mapping -- “Post-It Note Analysis”

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 43

*

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 44

Agenda

1. OPENING: Introduction + Examples + Systems

2. HISTORY: Your Personal Pursuit of Quality + HATChTM

3. DEFINITIONS and COMPARISONS:

a. Nursing Process and Circle of Success

b. Near Miss (vs. Near Hit) Analysis

c. Root Cause Analysis and Cause Mapping

d. QA and Attorney Client Privilege

4. DEMONSTRATION: Root Cause Analysis

5. APPLY: VIDEO CLIP

6. GROUP PRACTICE

7. CHANGE MANAGEMENT (“Never Events” vs. “Always Events”)

8. Q&A: ATP (As Time Permits)

11 Copyright 2014-2015 Direct Supply, Inc. All rights reserved 45

Add discussion of protected or not

protected – privileged

QA and Attorney Client Privilege

46 Copyright 2014-2015 Direct Supply, Inc. All rights reserved

Agenda

1. OPENING: Introduction + Examples + Systems

2. HISTORY: Your Personal Pursuit of Quality + HATChTM

3. DEFINITIONS and COMPARISONS:

a. Nursing Process and Circle of Success

b. Near Miss (vs. Near Hit) Analysis

c. Root Cause Analysis and Cause Mapping

d. QA and Attorney Client Privilege

4. DEMONSTRATION: Root Cause Analysis

5. APPLY: VIDEO CLIP

6. GROUP PRACTICE

7. CHANGE MANAGEMENT (“Never Events” vs. “Always Events”)

8. Q&A: ATP (As Time Permits)

11 Copyright 2014-2015 Direct Supply, Inc. All rights reserved 47

Everyone had snacks and drinks while watching the movie last night.

There are 6 empty glasses and several bowls in the living room.

Jason thought he could get everything into the kitchen in just two trips. He

grabbed three glasses in each hand by holding them from the top with his

fingers.

He was slowly stepping into the kitchen when Beth opened the pantry

door to put away a bag of chips. The door hit Jason’s arm and two of the

glasses shattered as they hit the ceramic tile floor.

Jason said, “Way to go Beth. Look what you did!”

Beth responded, “Jason, you shouldn’t have been carrying the glasses

like that!”

BROKEN GLASSES

1. ISSUE?

2. GOALS?

3. CAUSES?

4. SOLUTIONS / INTERVENTIONS?

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 48

1. ISSUE:

Broken

Glasses

2. GOALS:

Nothing Broken

Quick Cleanup

No Arguments

3. CAUSES:

Too many

Communication

Pantry Door

Ceramic Floor

Beth / Jason

4. SOLUTIONS:

No Party

Guests Clean-up

Plastic Cups

Use a Tray

Carpeted Floor

Re-Hang Door

Communicate

BROKEN GLASSES *

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 49

Goal

Impacted Effect

Cause /

Effect

Cause /

Effect

Cause /

Effect

Effect /

Cause

Effect /

Cause

Solution / Intervention

Solution / Intervention

Solution / Intervention

Issue

Broken Glasses

Goals Impacted

Nothing Broken

Glasses

shattered on

ceramic floor

Hit by the pantry

door, Jason

dropped the

glasses

Unannounced,

Jason entered

the kitchen

Jason picked up

and carried 6

glasses at once

Next morning,

Beth and Jason

divided up the

clean up

responsibilities

Unannounced,

Beth came out

of the pantry

opening door

into Jason’s arm

Beth and Jason

had guests over for

a party

They served

snacks and drinks

Party ended and

the clean up was

put off until

morning

Cause Mapping -- BROKEN GLASSES

No Party

Communicate

Re-hang pantry

door

Carpeted floor

Beth carries

glasses

Use a tray

Plastic cups

Guests Clean-up

Communicate

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 50

Agenda

1. OPENING: Introduction + Examples

2. HISTORY: Your Personal Pursuit of Quality

3. DEFINITIONS and COMPARISONS:

a. Nursing Process and Circle of Success

b. Near Miss (vs. Near Hit) Analysis

c. Root Cause Analysis and Cause Mapping

d. QA and Attorney Client Privilege

4. PRACTICE: Root Cause Analysis

5. APPLY: VIDEO CLIP

6. GROUP PRACTICE

7. Q&A: ATP (As Time Permits)

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 51

1. ISSUES:

Resident fall w/

injury – med error

2. GOALS:

Resident Safety

Hospitalizations

Correct med management

3. CAUSES:

Transcription error

Transcriber skill set

Administration error

Work load

4. SOLUTIONS:

Medication “check” process to verify

Med tech/Nurse verifying new med

Training/education

Med Error Example *

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 52

53

Step 1.

Issue /

Problem

Copyright 2014-2015 Direct Supply, Inc. All rights reserved

Step 1. Problem Outline

What Description

When Date

Time

Different,

unusual

Where Facility Name

Location

Care / Work

Process

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 54

55

Step 2.

Goals

Copyright 2014-2015 Direct Supply, Inc. All rights reserved

Sidebar: Examples of Quality Improvement Goal Categories and Goals

Goal Categories Specific Goals Goal Categories Specific Goals

Clinical

Mobility

Pressure Ulcers

Pain Management

Infections (C. difficile)

Médications (Antipsychotropics)

Risk and Safety

Severity

Patterns

Frequency

Resident Choice

Bathing

Mobility

Discharge

Person-Centered Care

Regulatory

osha

F Tags

K Tags

Life Safety Code

Organizational

Infrastructure

Staff stability

Hospitalizations

Consistent Assignments

Education

Orientation

Family education

Annual re-inservice

Mandatory inservices

Continuing Education

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 56

Step 3. Finding the Causes

RCA and Cause Mapping ("The Weed" and “

Post-It Note Analysis")

Step 3a. Asking Why

Step 3b. Cause

Mapping

"Post-It Note Analysis" Copyright 2014-2015 Direct Supply, Inc. All rights reserved

57

58

Step 4.

Interventions /

Solutions Copyright 2014-2015 Direct Supply, Inc. All rights reserved

Have You Ever Met Harry Houdini?

59

Collaborative Decision Making for Empowerment and Solutions*

Anne Ellett, Vice President Health Services; Silverado Senior Living, Inc. 60

Agenda

1. OPENING: Introduction + Examples

2. HISTORY: Your Personal Pursuit of Quality

3. DEFINITIONS and COMPARISONS:

a. Nursing Process and Circle of Success

b. Near Miss (vs. Near Hit) Analysis

c. Root Cause Analysis and Cause Mapping

d. QA and Attorney Client Privilege

4. PRACTICE: Root Cause Analysis

5. APPLY: VIDEO CLIP

6. GROUP PRACTICE

7. Q&A: ATP (As Time Permits)

11 Copyright 2014-2015 Direct Supply, Inc. All rights reserved 61

Step 1. Problem Outline

What Description Fall on parking lot pavement due to snow and ice

When Date XX / XX / XXXX (Sunday)

Time 11:15 pm / am

Different, unusual Unusual snow storm and unexpected thaw and refreeze

Where Facility Name The Center for Hope, Care and Recovery

Location North entrance drive way

Care / Work

Process

Resident, unescorted, returning to facility coming back from

Church

Scenario #1: Mr. Regis, 77 yrs. old, active, alert, visually impaired due to macular

degeneration, slipped & fell on snow/ice 11:20 AM, xx/xx/xx, Sunday, getting out

of daughter’s car, returning unescorted to building (fx elbow & shoulder)

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 62

Copyright 2014-2015 Direct Supply, Inc. All rights reserved

63

Step 2. List the Category and Specific Goals and Identify Impacts to Those Goals

Categories:

Clinical

Resident Choice

Organizational Infrastructure

Specific Medications Mobility Hospitalizations

Goals: Mobility Bathing Staff Stability

Infections

Person-centered care

Person-centered care

Consistent Assignment

Consistent Assignment

Pressure Ulcers

Pain Management Person-centered care

Resident Safety Physical Plant (snow / ice)

Goal Category Specific Goals Impact to Goals

Clinical Resident Safety Res. fall with injury

Org. Infrastruct. Physical Plant F Tag 323, Staff & Family Risk

Frequency:

Scenario #1: Mr. Regis, 77 yrs. old, active, alert, visually impaired due to macular

degeneration, slipped & fell on snow/ice 11:20 AM, xx/xx/xx, Sunday, getting out

of daughter’s car, returning unescorted to building (fx elbow & shoulder)

63

People, Hiring, HR

1. Newly contracted

snow/ice removal

P&P

1. Parking lot snow

starts removal @ 3” &

ongoing

2. Ice melt applied

based on conditions

Education

1.

Clinical, Medical

1.

Equipment

1. Broken weather radio

Environmental

1. Unseasonal storm

2. Sunday morning event

3. Saturday thaw and

refreeze lead to unusual

ice build-up

Management

1. Maintenance monitors

conditions ongoing

2. Contract compliance in

question

Step 3a. Ask WHY Fall Scenario: Mr. Regis

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 64

Physical Plant

(snow / ice) Resident Fall

Resident not

aware of unsafe

conditions

Unseasonal

storm

Thaw/ freeze

prior day

New snow

removal

contractor

Family drops

resident off near

the entryway

door of

community

Staff to inform or

escort resident to

car

Establish weekend

policy

Review contract

with current vendor

and replace if

necessary

Step 3b. Cause Mapping Step 4. Interventions / Solutions

Conditions not

monitored

(Maintenance

offsite)

Ice and snow

build up

Communicate with

family about calling

or escorting Dad

Replace brx

weather radio

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 65

Used with permission from: ThinkReliability

Step 4. Interventions/Solutions

Owner Cause Intervention/Solution Due Date Admin New snow removal contractor Review contract with current

vendor and replace if necessary

Maintenance Conditions not monitored

(Maintenance offsite)

Replace weather radio

Admin Conditions not monitored

(Maintenance offsite)

Establish weekend policy

Nursing Family drops resident off near

front door

Communicate with family about

calling or escorting

Nursing Resident not aware of unsafe

conditions

Staff to prepare to escort resident

back in

*

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 66

Agenda

1. OPENING: Introduction + Examples + Systems

2. HISTORY: Your Personal Pursuit of Quality + HATChTM

3. DEFINITIONS and COMPARISONS:

a. Nursing Process and Circle of Success

b. Near Miss (vs. Near Hit) Analysis

c. Root Cause Analysis and Cause Mapping

d. QA and Attorney Client Privilege

4. DEMONSTRATION: Root Cause Analysis

5. APPLY: VIDEO CLIP

6. GROUP PRACTICE

7. CHANGE MANAGEMENT (“Never Events” vs. “Always Events”)

8. Q&A: ATP (As Time Permits)

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 67

STEP 2: Goals Not Met

1. ISSUE/PROBLEM: Resident fell while self-toileting

2. GOALS NOT MET: <Instructions: Each group the identify the

goals not met. Select a spokesperson and be prepared to report out.>

TOOLS: a] Sidebar: Examples of QI Categories and Goals b] ThinkReliability worksheet and c] HATChTM

1st GROUP

PRACTICE:

10 min.

Copyright 2014-2015 Direct Supply, Inc. All rights reserved

3. FINDINGS / CAUSES:

a. Woman w/ dementia

b. In the building 1+ yrs

c. 2-3 falls/m. (toileting)

d. Q2 check and change

e. Not actually being toileted

f. Staff thought she was incontinent

4. INTERVENTIONS:

a. Map patterns and determine

retention (scanner)

b. Care plan and communicate

c. Train on compliance with care plan

68

Sidebar: Examples of Quality Improvement Goal Categories and Goals

Goal Categories Specific Goals Goal Categories Specific Goals

Clinical

Mobility

Pressure Ulcers

Pain Management

Infections (C. difficile)

Médications (Antipsychotropics)

Risk and Safety

Severity

Patterns

Frequency

Resident Choice

Bathing

Mobility

Discharge

Person-Centered Care

Regulatory

osha

F Tags

K Tags

Life Safety Code

Organizational

Infrastructure

Staff stability

Hospitalizations

Consistent Assignments

Education

Orientation

Family education

Annual re-inservice

Mandatory inservices

Continuing Education

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 69

R

3. Environment

Holistic

Approach to

Transformational

ChangeTM

The HATChTM

Model

70

70

Work Place

Practice

1-Do

2-Hire

3-Train

4-Mentor

5-Retain

6-Communicate

Environment

1-Five Senses

2-Safety

3-Comfort

4-Cleanliness

5-Compassion

Leadership

1-Vision

2-Team

3-Culture*

4-Finance

5-Processes

6-Education

7-Development

8-Human Rsrcs.

9-Physical Plant

CULTURE* 1-Trust

2-Quality

3-Patience

4-Sanctuary

5-Friendship

6-Fulfilment

7-Engagement

8-Communicate

Community

and Family

1-HOME

2-Society

3-Connection

4-Engagment

5-Communicate

6-

Compliance

1-Knowledege

2-Awareness

3-Experience

4-Preparation

5-Consistency

Which domains can

you focus on when

developing

interventions?

Clinical

Practice

1-Body

2-Mind

3-Emotions

*

71

STEP 4: Develop Interventions

1. ISSUE/PROBLEM: Resident drowned while self-bathing

2. GOALS NOT MET: Clin. Practices, Bathing, PCC, Communicate,

Consistent Assignments??, …

2nd GROUP

PRACTICE:

15 min.

3. FINDINGS / CAUSES:

a. This Resident wanted a bath but residents were usually showered

b. Tub room tub room was used for storage

c. Resident was not noticed missing for several hours

d. Staff stated that they did not know his preference for bathing

4. INTERVENTIONS: <Instructions: Each will group develop several

interventions. Select a spokesperson and be prepared to report out.>

Copyright 2014-2015 Direct Supply, Inc. All rights reserved

TOOLS: a] Sidebar: Examples of QI Categories and Goals b] ThinkReliability worksheet and c] HATChTM

72

Center for Hope and Healing (99 beds)

73 http://www.targettimber.com/timber-frame-nursing-homes

1st Data Point: Number of falls/month

What’s your observation?

Complete an entire

4-Step RCA Process

Center for Hope and Healing (99 beds)

Instructions:

Each group will:

1.Follow the 4-step RCA Process we just discussed

a] Issue b] Goals c] Causes d] Interventions

2.Complete the appropriate RCA documentation

3.Define any lessons learned using the tools

4.Report out to the class

3rd GROUP

PRACTICE:

30 min.

Copyright 2014-2015 Direct Supply, Inc. All rights reserved

Your Turn

74

75

Center for Hope and Healing (99 beds)

Step 1. Problem Outline

What Description

When Date

Time

Different, unusual

Where Facility Name

Location

Care / Work

Process

76

Center for Hope and Healing (99 beds)

Step 2. List the Category and Specific Goals and Identify Impacts to Those Goals

Categories:

Clinical

Resident Choice

Organizational Infrastructure

Specific Medications Mobility Hospitalizations

Goals: Mobility Bathing Staff Stability

Infections

Person-centered care

Person-centered care

Consistent Assignment

Consistent Assignment

Pressure Ulcers

Pain Management Person-centered care

Goal Category Specific Goals Impact to Goals

Frequency:

76

77

Center for Hope and Healing (99 beds)

Step 3a. Ask WHY

Step 3b. Cause Mapping

77

Step 4. Interventions/Solutions

Owner Cause Intervention/Solution Due Date

INTERVENTIONS:

1. Mandated change for chart times

2. Re-education of staff & resident perceptions

Center for Hope and Healing (99 beds)

78

79

Center for Hope and Healing (99 beds)

How it really turned out …

Some possible GOALS:

1. INCREASE Residents dining participation

AND

2. REDUCE:

a. Falls

b. Weight loss

c. Food Complaints

d. Behaviors / Increase socialization

e. Pressure ulcers / Increase movement

80

Center for Hope and Healing (99 beds)

Center for Hope and Healing (99 beds)

81

2nd Data Point: % Participation

Congregate Dining

Center for Hope and Healing (99 beds)

82

1st Data Point: Falls/month 2nd Data Point: % Participation

Additional Findings:

1st Data Point:

Steady increasing of resident falls

2nd Data Point:

Low participation in congregate dining program

3rd Data Point:

YTD, 67% of the falls appeared to be at meal times

4th Data Point:

Noticeably higher % of call lights not answered timely at

meal times

83

Center for Hope and Healing (99 beds)

83

Additional Findings:

1. Meal Service Schedule

a. In-room and social dinner served simultaneously

b. Assisted dining served second

2. Staff Routinely Completed Charting During Meal-times

3. Perceptions

a. RESIDENTS:

1) Meal served sooner in resident rooms

2) Staff not available to assist

b. STAFF:

1) “Other things” to do at meal time

2) Delivering the “meals to the residents” is easier and quicker

than transporting the “residents to the meals”

84

Center for Hope and Healing (99 beds)

84

Agenda

1. OPENING: Introduction + Examples + Systems

2. HISTORY: Your Personal Pursuit of Quality + HATChTM

3. DEFINITIONS and COMPARISONS:

a. Nursing Process and Circle of Success

b. Near Miss (vs. Near Hit) Analysis

c. Root Cause Analysis and Cause Mapping

d. QA and Attorney Client Privilege

4. DEMONSTRATION: Root Cause Analysis

5. APPLY: VIDEO CLIP

6. GROUP PRACTICE

7. CHANGE MANAGEMENT (“Never Events” vs. “Always Events”)

8. Q&A: ATP (As Time Permits)

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 85

400+ Available Theories of Change Management

A -0 - E - - K - - R - - U -

Acquiescence Effect Ego Depletion Kin Selection see Prosocial Behavior Rationalization Trap Ultimate Attribution Error

Acquired Needs Theory Elaboration Likelihood Model - L - Reactance Theory Ultimate Terms

Activation Theory Empathy-Altruism Hypothesis Lake Wobegon effect Reasoned Action, see Planned Behavior Theory Uncertainty Reduction Theory

Actor-Observer Difference Endowed Progress Effect Language Expectancy Theory Realistic Conflict Theory Unconscious Thought Theory

Affect Infusion Model Endowment Effect Law of Attraction Recency Effect Urban-Overload Hypothesis

Affect Perseverance Epistemological Weighting Hypothesis Lazarus Theory see Appraisal Theory Reciprocity Norm - V -

Aggression Equity Theory Leader-Member Exchange Theory Regret Theory Valence Effect

Ambiguity effect ERG Theory Learned Helplessness Theory Reinforcement-Affect Theory VIE Theory see Expectancy Theory

Amplification Hypothesis Escape Theory Learned Need Theory see Acquired Needs Theory Relative Deprivation Theory - W -

Anchoring and Adjustment Heuristic Expectancy Violations Theory Least Interest Principle Relationship Dissolution, see Terminating Relationships Weak Ties Theory

Anticipatory Regret see Regret Theory Expectancy Theory Linguistic Inter-group Bias Representativeness Heuristic Wishful Thinking see Valence Effect

Appraisal Theory Explanatory Coherence Locus of Control Repulsion Hypothesis Worse-Than-Average Effect see Below-Average Effect

Attachment Theory Extended Parallel Process Model Looking-glass Self Restraint Bias - X -

Attachment Style External Justification Love Risk Preference - Y -

Attitude Ethnocentric Bias see Group Attribution Error - M - Risky Shift Phenomenon Yale Attitude Change Approach

Attitude-Behavior Consistency Extrinsic Motivation Matching Hypothesis Roles

Attribution Theory - F - Mental Models see Schema - S -

Automatic Believing False Consensus Effect Mere Exposure Theory Sapir-Whorf Hypothesis

Augmenting Principle False Memory Syndrome Mere Thought Effect Satisficing

Availability Heuristic Fatigue Minimum Group Theory Scapegoat Theory

- B - Focalism Minority Influence Scarcity Principle

Balance Theory see Consistency Theory Focusing Effect Mood-Congruent Judgment Schema

Barnum Effect see Personal Validation Fallacy Forced Compliance Mood memory Selective Exposure

Belief Bias Forer Effect see Personal Validation Fallacy Multi-Attribute Choice Selective Perception

Belief Perseverance Four-factor Model - N - Self-Affirmation Theory

Below-Average Effect Filter Theory Negative Face see Politeness Theory Self-Completion Theory

Ben Franklin Effect Framing Neglect of probability bias Self-Determination Theory

Bias blind spot Friendship Non-Verbal Behavior Self-Discrepancy Theory

Bias Correction Frustration-Aggression Theory Normative Social Influence Self-Enhancement see Impression Management

Biased sampling Fundamental Attribution Error Norms see Social Norms Self-Enhancing Bias see Self-Serving Bias Body language see Non-verbal Behavior - G - - O - Self-Evaluation Maintenance Theory

Bounded Rationality Gambler's Fallacy Objectification Self-Fulfilling Prophecy

Buffer effect of Social Support Goal-Setting Theory Object Relations Theory Self-Monitoring Behavior

Bystander Effect God Terms see Ultimate Terms Operant Conditioning Self-Perception Theory

- C - Group Attribution Error Opponent-Process Theory. Self-Protective Bias see Self-Serving Bias

Cannon-Bard Theory of Emotion Group Locomotion Hypothesis Optimism Bias see Valence Effect Self-Regulation Theory

Cautious Shift see Risky Shift Phenomenon Group Polarization Phenomenon Other-Enhancement see Impression Management Self-Serving Bias

Central Route see Elaboration Likelihood Model Group-serving Attributional Bias see Group Attribution Error Outcome Dependency Self-Verification Theory

Certainty Effect Groupthink Out-Group Bias see In-Group Bias Side Bet Theory

Charismatic Terms see Ultimate Terms - H - Out-Group Homogeneity Sleeper Effect

Choice Shift see Risky Shift Phenomenon Halo Effect Overconfidence Barrier Small World Theory

Choice-supportive bias Hedonic Relevance see Correspondent Inference Theory Overjustification Effect Social Comparison Theory

Choice Theory see Control Theory Heuristic-Systematic Persuasion Model - P - Social Desirability Bias

Classical Conditioning Hostile Media Phenomenon Perceived Behavioral Control see Planned Behavior Theory Social Exchange Theory

Clustering Illusion Hot Hand Phenomenon Perceptual Contrast Effect Social Facilitation

Coercion Hindsight Bias Perceptual Salience Social Identity Theory

Cognitive Appraisal Theories of Emotion Hyperbolic discounting Peripheral Route see Elaboration Likelihood Model Social Impact Theory

Cognitive Dissonance - I - Personal Construct Theory Social Influence

Cognitive Evalution Theory Illusion of Asymmetric Insight Personal Validation Fallacy Social Judgment Theory

Commitment Illusory Correlation Personalism see Correspondent Inference Theory Social Learning Theory

Communication Accommodation Theory Imagination Inflation see False Memory Syndrome Persuasion Social Loafing

Compensation Imagined Memory Persuasive Arguments Theory Social Norms

Confirmation Bias Impact Bias Placebo Effect Social Penetration Theory

Conjunction Fallacy Implicit Personality Theory Planning Fallacy Social Proof see Informational Social Influence

Consistency Theory Impression Management Planned Behavior Theory Social Representation Theory

Constructivism Inattentional Blindness Plasticity Social-Role Theory

Contact Hypothesis Information Bias Pluralistic Ignorance Sociobiology Theory

Control Theory Information Manipulation Theory Polarization Source Credibility

Conversion Information Processing Theory Politeness Theory Speech Act Theory

Contagion Informational Social Influence Positive Face see Politeness Theory Spiral of Silence Theory

Conversion Theory In-Group Bias Positive psychology Stage Theory

Correspondence Bias In-Group Linguistic Bias see In-Group Bias Positive Test Strategy see Confirmation Bias Stereotypes

Correspondent Inference Theory Inoculation Positivity Effect Stockholm Syndrome

Counter-Attitudinal Advocacy (CAA) Insufficient Punishment Post-Decision Dissonance Story Model

Counterfactual Thinking Interpersonal Deception Theory Power Stimulus-Value-Role Model

Covariation Model Interpersonal Expectancy Effect The Pratfall Effect Strategic Contingencies Theory

Credibility Interview Illusion Primacy Effect Subjective Norms see Planned Behavior Theory

- D - Intrinsic motivation Priming Subliminal Messages

Decisions Investment Model Private Acceptance see Informational Social Influence Sunk-Cost Effect

Deindividuation Invisible Correlation see Illusory Correlation Propinquity Effect Symbolic Convergence Theory

Devil Terms see Ultimate Terms Involvement Prosocial Behavior Symbolic Interaction Theory

Disconfirmation bias Ironic Reversal Prospect Theory - T -

Discounting - J - Pseudo-certainty effect see Certainty Effect Terminating relationships

Dissonance see Cognitive Dissonance James-Lange Theory of Emotion Psychological Accounting Theory of Mind

Drive Theory Justification of Effort Public Compliance see Informational Social Influence Three-factor Theory see Acquired Needs Theory

Durability bias Just-world phenomenon Pygmalion Effect see Self-Fulfilling Prophecy Transtheoretical Model of Change

Two-Factor Theory of Emotion

http://changingminds.org/explanations/theories/a_alphabetic.htm 86

So Which One?

http://rapidbi.com/kurt-lewin-three-step-change-theory/ 87

File:Iceberg.jpg (From Wikipedia, the free encyclopedia)

http://en.wikipedia.org/wiki/File:Iceberg.jpg

UNFREEZE = Decide, Plan, Strategize, use data, ENGAGE; let go of old patterns

CHANGE = Engage and Communicate; Implement Your Plan:

= Create AWARENESS and BUY-IN

RE-FREEZE = Manage Resistance

= Beat the Drum

= Monitor and Modify the “Changing” Environment

= Without refreezing, it is easy to backslide into the old ways.

http://www.ehow.com/way_5870000_strategies-managing-change-nursing.html

Strategies for Managing Change in Nursing By Ngozi Oguejiofo, eHow Contributor 88

“Never Events” vs. “Always Events”

89

“Never Events” vs. “Always Events”

As a result of today, what are you always going to do?

1.

90

Agenda

1. OPENING: Introduction + Examples + Systems

2. HISTORY: Your Personal Pursuit of Quality + HATChTM

3. DEFINITIONS and COMPARISONS:

a. Nursing Process and Circle of Success

b. Near Miss (vs. Near Hit) Analysis

c. Root Cause Analysis and Cause Mapping

d. QA and Attorney Client Privilege

4. DEMONSTRATION: Root Cause Analysis

5. APPLY: VIDEO CLIP

6. GROUP PRACTICE

7. CHANGE MANAGEMENT (“Never Events” vs. “Always Events”)

8. Q&A: ATP (As Time Permits)

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 91

Reasons For Attending: DID WE HIT THEM?

WHAT:

Learn how to “do”, “document” and “teach” Root Cause

Analysis (RCA)

SO WHAT:

Protect your Residents and Staff from injuries by applying

RCA (Root Cause Analysis)

NOW WHAT:

Acquire, Understand, Apply

THEN WHAT:

Share

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 92

“I did then what I knew then,

when I knew better,

I did better.”

The Late Maya Angelou Presidential Medal of Freedom Recipient

Thank You Ray Miller

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 93

Sustaining Quality: Making Root Cause

Analysis Practical and Productive

Handout 1

We will begin at

9 AM Ray Miller, MSOSH, GP

Dir. Risk/Safety Solutions

Some possible GOALS:

1. INCREASE Residents dining participation

AND

2. REDUCE:

a. Falls

b. Weight loss

c. Food Complaints

d. Behaviors / Increase socialization

e. Pressure ulcers / Increase movement

2

Center for Hope and Healing (99 beds)

Center for Hope and Healing (99 beds)

3

2nd Data Point: % Participation

Congregate Dining

Center for Hope and Healing (99 beds)

4

1st Data Point: Falls/month 2nd Data Point: % Participation

Additional Findings:

1st Data Point:

Steady increasing of resident falls

2nd Data Point:

Low participation in congregate dining program

3rd Data Point:

YTD, 67% of the falls appeared to be at meal times

4th Data Point:

Noticeably higher % of call lights not answered timely at

meal times

5

Center for Hope and Healing (99 beds)

5

“Never Events” vs. “Always Events”

As a result of today, what are you always going to do?

1.

2.

3.

4.

5.

6.

7. 6

“I did then what I knew then,

when I knew better,

I did better.”

The Late Maya Angelou Presidential Medal of Freedom Recipient

Thank You Ray Miller

Copyright 2014-2015 Direct Supply, Inc. All rights reserved 7