Organizational Systems and Quality Leadership
A. Explain the general purpose of conducting a root cause analysis (RCA).
A root cause is a factor that leads to a non-conformance or derails a process and it should resolved permanently by eliminating it thereby improving processes. To help remove these root cause factors, a root cause analysis has to be performed (Epstein & Turner, 2015). Root cause analysis is the collective term that describes a range of tools, approaches, and techniques that are carried out to uncover or determine the main cause of a problem within a system or process.
The figure above shows the six steps of RCA as defined by IHI.
The first step is to take immediate action. The actions to be taken may include making the area of incident clear, preserving the scene to protect evidence, and notifying all relevant parties. It is vital to note that the incident investigations start at this this early stage, through the collection and preserving perishable evidence.
Planning for investigations is vital as it guarantees high quality, detailed, and thorough investigations. One should plan to ensure the investigations are systematic and complete. Things that should be thought about include:
Data collection is vital for the investigations and it can be collected through interviewing the people involved, as well as getting information from documents, equipment, and from the scene of the incident.
Characteristically, accidents or incidents are just a result of single event, but a systematic chain of events. Investigators need to understand the series of events in order to identify the root cause. They should seek to identify the root cause as well as the underlying causes and direct causes.
After the root cause and direct cause of the incident has been identified, it is upon the investigative agencies to come up with measures or corrective actions that can solve the root cause (Epstein & Turner, 2015). These measures are then implemented
This is the sixth and the last process of the RCA process. It occurs when all the outstanding issues have been dealt with and the findings communicated to the management team and all other employees.
2. Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome.
The first step would be for the investigators to secure the scene of incident, all documents relating to Mr. B medical history, and notify all relevant parties such as the management of the hospital, the doctors and nurses who attended to the patient, and family members of Mr. B.
This step will require the management team to lead investigator or the management team of the hospital to plan for the investigations:
Data collection is vital for the investigations and it can be collected through interviewing the people involved. In this case, the investigators should look into the procedure used when admitting Mr. B in the hospital as well as all the medication he received, the procedures he underwent such as the hip replacements, and the medication and procedures he received during his recuperation period before he was transferred to another hospital.
After all the data has been collected, the investigators should analyze the main reason why this incident occurred. This is the only way they can be able to know the root cause of this incident. In this case scenario, the root cause is that after the medical treatment team thought Mr. B was in stable condition, they adjourned all close care to him and he was just left in his room with his son who is not qualified to offer any kind of help to him incase his condition deteriorates (Epstein & Turner, 2015). Mr. B was an old man of 65 years old and a hip replacement procedure is a very big surgical procedure for such an old patient. For this reason, it would have been prudent for at least one hospital staff to be at his bedside at all times until he is adjudged to be out of danger and discharged to go home. His medical records from previous hospitals should also have been to ensure that the staffs taking care of him know that he should be on oxygen mask to avoid complications.
After the root cause and direct cause of the incident has been identified, it is upon the investigative agencies to come up with measures or corrective actions that can solve the root cause. The corrective actions here should be
After the investigations have been completed, it is important for the investigating team to meet with the hospital management team and inform them of what they found they should also give them their recommendations for implementation and communication to the other members of the hospital.
B. Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome.
The main reason why Mr. B lost his life was because of some fundamental flaws that in the admission procedure and the post-surgery care was not suitable for a patient his age as well. To prevent this incidents from happening, the management team should come up with fundamental changes with the system. There should be a policy procedure that requires the admitting nurse to get all records about the patient (Stephen, 2015). All the important information should be recorded in the admitting form to ensure that all medical professions who will handle the patient know and understand all the sensitive and important information. Like in this case, the important of the patient to be monitored for oxygen level within short intervals. For patients over the age of 55 years undergoing major surgical procedures, they should be monitored closely by a qualified professional at all times during their recuperation period. This is very important as it would ensure they are offered high quality emergency care in the event they need it.
1. Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan.
Kurt Lewin’s three-phase change model is generally known as the Unfreeze, Change, Freeze or the Refreeze model of change management. Even though this model might appear as too simplistic for a complicated process such as change process and management, it offers ingenious solutions of implementing change and change management in an institution (Allan, 2016).
The unfreeze stage
This is the first phase of this stage and it is known as the unfreeze stage. It involves getting ready for change. The organisation seeks to understand the changes that need to be implemented in the organisation and accepting that for the organisation to move forward, old ways have to be changed and new ones put in place (Stephen, 2015).
In this case scenario, the management team will use the recommendations done by the investigations to change the procedures of admitting patients. They should also change how they give post-surgical care to older patients after they undergo major surgical procedures such as hip replacement
The change stage
This is the second stage and it involves implementing the changes that had been identified. During this stage, the change managers must involve all the employees to ensure that they understand why the changes being implemented are necessary. This is very important as it helps reduce resistance to change which can derail the change process (Epstein & Turner, 2015). This stage has to be done under a strict deadline and the implementers of the change process must observe the set deadline at all times to avoid unnecessary delays some of which might be as a result of abstractions caused by parties opposed to the changes.
In the case scenario, this stage will see the managers involving all employees in understanding the changes that will be implemented are important and that all employees will be required to help he organisation achieve this changes. A timeline for the change implementation should also be drawn to ensure that the changes are implemented.
The Freeze stage
This is the last stage of the change process and it involves ingraining the changes being implemented into the organisation policy as well as its culture. These changes would be the new way of doing things in the organisations.
This stage will involve the implementing the changes that have been agreed upon in the organisation. Head of department should see that the changes proposed are implemented in their departments to guarantee that no incident occurs.
C. Explain the general purpose of the failure mode and effects analysis (FMEA) process.
Just like RCA, the main purpose of conducting a FMEA process is to strengthen a system or procedures by identifying its weaknesses and coming up with measures to eliminate them. This tool is used in health institutions to improve their process and procedures.
1. Describe the steps of the FMEA process as defined by IHI.
Implementing a FMEA requires a manager or investigator to follow a systematic procedure. This procedure has a number of steps that need to be adhered to in order to come up to deductions that can help improve the system being implemented. The initial stage requires the investigators reviewing the existing system and tries to identify weaknesses that have brought about the incident that has resulted in the FMEA process (Stephen, 2015). This will be flowed by a deep analysis of the system to identify what led to the failures, listing down the failures, and then ranking them from the most serious failure to the least serious one. After ranking the failures, the investigating team should now look as to chances of these failures reoccurring and then calculating the RPN (Allan, 2016). Tis would ensure that the chances of the failures reoccurring are minimal.
2. Complete the attached FMEA table by appropriately applying the scales of severity, occurrence, and detection to the process improvement plan proposed in part B.
|Steps in the Improvement Plan Process *||Failure Mode||Likelihood of Occurrence|
|Likelihood of Detection|
|Severity(1–10)||Risk Priority Number(RPN)|
|Admitting nurse should get all information about the patient||Did not know the patient would need constant or regular oxygen check ups||3||5||6||120|
|No oxygen was given to the patient when he needed||This did not help the patient and it made the patient go into a coma||3||6||6||108|
|Failing to appreciate the fact that a 65 year old patient had undergone a serious surgical procedure||Did not offer critical care when it was needed the most||4||6||4||96|
|Failure to offer critical emergency care when the patient needed it||Failure to offer critical medical care||4||3||6||72|
|Failure to have proper admission procedures at the hospital||Wrong medication offered||5||2||4||40|
|Total (sum of all RPN’s): ||436|
D. Explain how you would test the interventions from the process improvement plan from part B to improve care.
After installing any new system, it is important to come up with ways to test and see if it works as expected. The best way to test this new system is to put it in place and then give it a grace of three months then come up and evaluate if it is working. This will enable the management team to analyze evaluate the system and identify all the failures and correct them. The proposed systems will be put in place starting with admission system that will ensure the admitting nurse gets all the required information about the patient. There will be forms that this information should be filled to ensure the records are taken and stored will. Good records taking will ensure that all other required procedures fall in place. For example, all medical practitioners handling the patient will ensure that no allergic medication is given and that the patient are on oxygen mask at all times. An evaluation of this system should be evaluated after three months to see how many errors occurred.
E. Explain how a professional nurse can competently demonstrate leadership in each of the following areas:
• Promoting quality care
Nurses play a crucial role in offering good care to patients. They can show leadership in promoting quality care by improving their skills through enrolling in specialized training that can enable them learn new skills of giving good care to patients (Stephen, 2015).
• Improving patient outcomes
Nurses can help improve patient outcomes by applying their skills to ensure that patients are treated well and that they get the best possible healthcare(Allan, 2016) . They can show leadership by urging their fellow professionals to treat patients well.
• Influencing quality improvement activities
In this regard, nurses can show leadership by talking to the management team on behalf of other nurses on the importance of the hospital buying the best quality tools that can enable them to perform their duties effectively
Discuss how the involvement of the professional nurse in the RCA and FMEA processes demonstrates leadership qualities.
Nurses can show their leadership in participating in RCA and FMEA processes by working hand in hand with investigators to uncover the core reasons why there have been systematic failures in the system they can also offer recommendations on measures that can be put in place to help ensure the failures do not happen again (Stephen, 2015).
Francis, B., & George, T. (2015). RCA and FMEA process. New York, NY: Rutledge
Sarah, F. (2016). Nursing leadership and improvement of procedures. New York, NY: Routledge.
Stephen, J. (2015). How to offer high quality healthcare to patients. Philadelphia, PA: F.A. Davis Company.
Allan, F. (2016). Nursing leadership. New York, NY: Routledge.
Catalano, J. T. (2015). Nursing now!: Today’s issues, tomorrow’s trends. Philadelphia, PA: F.A. Davis Company.Epstein, B., & Turner, M. (2015). The Nursing Code of Ethics: Its Value, Its History. Online Journal of Issues in Nursing, 20(2)
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