Running Head: Organizational Systems and Quality Leadership Task 2 1

Organizational Systems and Quality Leadership Task 2

C489: SAT Task 2-1217

ORGANIZATIONAL SYSTEMS AND QUALITY LEADERSHIP TASK 2 2

Organizational Systems and Quality Leadership Task 2

A. Root Cause Analysis (RCA)

Root Cause Analysis (RCA) is a method of problem solving employed in the

identification of the root causes of faults or problems which is widely applied in medicine and other

professions. The root cause is an inherent flaw in a system which gives rise to errors to occur. (IHI,

2018) in the course of a root cause analysis, the primary flaw that gave rise to the error will be

identified and eliminated and future occurrence of such error forestalled. The general purpose of

the root cause analysis is in proactive management occasioned by the identification of the root

cause of a problem. A factor is taken as the root cause of a problem if future recurrence of the

problem can be prevented from eliminating the factor.

A1. RCA Steps: Once a mistake has been identified in a system such as patient care in a health

care system, an RCA team made up of multidisciplinary healthcare professionals is constituted to

look into the error and they will proceed by engaging the six steps of root cause analysis into action

(IHI, 2018) Prior to step one, the adverse event identified and a RCA team is formed. The RCA

team constituted to look into the error and identify the cause is best to be made up of
ORGANIZATIONAL SYSTEMS AND QUALITY LEADERSHIP TASK 2 3

multidisciplinary health care professionals which will encourage objectivity a greater chances to

success which in process improvement.

Step One: The first step in carrying out the RCA is to identify what happen. This step can be

carried out by the team reflecting on the situation to identify where the error occurred. At this

phase, initial information gathering on event takes place and the evidence is discovered and

collected. The RCA team goes through incident reports raised after the incident and reconcile the

reports with their own understanding or mental picture of the incident. The next step in this phase

is to develop a basic flowchart of actions which will help recreate the incident, based on

information available and also revisiting the input from parties involved as at the time of the

incident. This step can serve as an event log whose purpose can help the RCA team to understand

the areas of lapses judging from information on ground (IHI,2018). A variety of methods can be

employed by the RCA team to collect data concerning the incident. The team can review charts,,

closed circuit televisions where applicable and incident reports, staff interviews, patient statements

from surveys, and eye witness accounts. Once data collection is completed, the flowchart is

updated with relevant information which describes a step by step recapitulation of the actual

happenings in the incident devoid of estimations and approximations and the team can move on to

step 2.

Step Two: Here in step two of the process, the attention of the RCA team is shifted from “what

happened” to “what should have happened”. The RCA team reviews the policies and procedures set

aside by the establishment, or any other laid down rules of engagement to gain knowledge of

specific steps which the parties involved in the mishap should have followed which could have

averted the incident. An additional flowchart is designed which will describe how the process is

designed in line with the policies and regulations of the hospital. This flowchart is different from
ORGANIZATIONAL SYSTEMS AND QUALITY LEADERSHIP TASK 2 4

the one in step one which described the steps taken by the partied involved which gave rise to the

incident.

Step Three: this step ushers the RCA team into the main event of determining the root cause of a

mishap. The two flowcharts created in step one and two above will be compared and contrasted.

These two flow charts answer the question of “what happened” and “what should have happened”.

the steps in the first flowchart which is the steps taken by the parties involved which gave rise to

the error is correlated with the steps in the second flow chart which us according to the laid down

rules of the establishment. Every lapses and irregularities in the order of events that gave rise to the

mishap will become obvious as the plausible causes for the incident. It is now the responsibility of

the RCA team to focus on the obvious discrepancies which they can then deconstructed into either

contributing factors to the incident or the direct causes. To further classify the lapses and classify

them into a category of error, the team will proceed into additional probing by asking “The Five

Whys”. which will unravel more information on the discrepancy(ies) that culminated into the

mishap. This new set of information unraveled will guide the team into properly classifying the

error into a contributing factor or a root cause. A Root or a Direct cause of an adverse event is the

defining step in a system or a process which makes the system or the process open to errors that

bring about adverse events. On the other hand, contributing factors are errors in a system or a

process that serve as catalysts for the root cause to initiate an adverse event. They are often known

as situational errors, and not a system error (IHI, 2018).

Once this classification into root cause and contributory factors is achieved, the root cause is further

classified into one or more subcategories. The RCA team can achieve this further classification

using the fishbone or cause and analysis diagram. In the health care system the specific categories
ORGANIZATIONAL SYSTEMS AND QUALITY LEADERSHIP TASK 2 5

that are analyzed includes patient characteristics, work environment, individual staff member, task

factors, team factors, institutional context, and organizational and management factors (IHI,2018).

Step four: at this stage of the RCA process, the team develops a causal statement which consists of

a three-part explanation of the incident. The first part explains the root cause of the adverse event

which led the system into being vulnerable to the errors. The second part explains the effect which

the root or direct cause has on the system or process. The third part of the statement describes the

adverse outcome as orchestrated by the root or direct cause and also the role of the contributing

factors as they all yield to adverse outcome.

Step Five: In this step of the RCA process, the team create a comprehensive list of

recommendations which will help the establishment prevent futuristic reoccurrence of the adverse

events. The essence of the process in this step is to use the SMART Goals as suggested by the

National Patient Safety Agency to eliminate the root cause of the identifies system error and has a

futuristic purpose of forestalling future reoccurrence. (IHI, 2018).

Step six At the final step of the RCA process, the team drafts a summary of their findings in the

exercise which will be shared with administration of the establishment and will be consequently

copied to all parties in staff members involved in that particular incident. This step helps the

establishment to create and promote awareness, educate the staff and members of the public,

increase compliance with laid down rules and prevent the future occurrence of the adverse

incidence.

A2. Causative and Contributing Factors: In the scenario described for this task, the patient

suffered from a heart failure. The benzodiazepines administered to the patient for sedation

potentiated the effects of the opoids which brought about respiratory depression. This sentinel event
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outcome was caused by inability of the staffs to appropriately monitor the sedative drug

administered to the patient. The sedation was administered to the patient without close monitoring

by the nurses to prevent possible adverse effects and life-threatening interactions of the sedation.

Factors that contributed to this incident includes inadequate staffing levels, poor level of

communication, medications given for conscious sedation, inability of the nurse to recognize the

need for supplemental oxygen, inability of the staff to comply with rules and regulations on

conscious sedation, and the inability of the physician to be conscious of the interactions and

adverse effects of the medication administered for sedation.

B: Improvement Plan

A process improvement plan is necessary to decrease the likelihood of a concurrence of

the scenario outcome and also improve patient safety and well-being. The improvement plan I will

propose for this sentinel event outcome will include a critical review and updating of the hospital

policies on the mandatory staffing levels for procedures, use and monitoring of medications for

sedation-including doses, adverse effects, and interactions. Furthermore in the improvement plain is

to organize an initial and annual training for members of the staff of the establishment on policy

and patient safety. Certification for training will be issued out to participants upon conclusion and

will be documented in competency file for members of the staff. The establishment will be

instructed to review and update their rules and regulations to include QI and Timeout sheet. Part of

the updates to be made includes making it compulsory that all patients be provided with

supplement Oxygen therapy until their condition return to base line health status. Furthermore,

before sedatives are administered to patient, the hospital administrator should be notified by the ER

or any other staff in charge so that a nurse will be assigned to monitor the procedure from start to
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finish. The nurse nurse to be assigned this new responsibility will be stripped off all previous

duties and shifts and also have a new competent nurse assigned to take over from her duties so as to

prevent divided attention as she takes up the task of recovering the patient from anesthesia. By so

doing, bed side monitoring of post-procedural sedation will be improved and the chances of similar

incident as the sentinel event outcome occurring will be drastically reduced.

B1. Change Theory: according to Lewin’s Theory of Change, change in a system or a process

occurs in three stages which includes: first, unfreezing, second, actual change, and third, freezing.

The first stage of unfreezing deals with the disentanglement from current state of the system or the

process. This is achieved by the parties involved first realizing the need for change by reviewing

the undesirable status of the current system or process and then envisaging the benefits that will be

ushered in with the proposed change. The more time the parties involved spend on envisaging how

the new system will go ahead to make things better makes it easier for the parties to be willing to

let go of the current system and accept the change. Relating to the sentinel even in the scenario, the

unfreezing stage of the theory can be achieved by educating the ER staff on the events that

occurred which led to the demise of the patient. It would be highlighted that the patient could not

make it because of lack of adequate manpower in the hospital making it difficult to get a nurses

that will monitor the patient on admission. By so doing, the parties involved will be informed on

why the current system is to be abandoned and a new system of running procedures adopted which

will correct the discrepancies inherent in the old system. Having a system that will assign a staff on

stand-by to monitor a patient with heart problems on sedation until patient returns to baseline status

can help to ensure that no other patient dies from inadequate monitoring.

The stage of implementing the change proper is the second stage. This is the stage where the

difficulties associated with change is manifest. These difficulties usually manifest as fears and
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frustrations due to uncertainties about the new system but can be overcome with education and

resources. This stage can also be made less challenging for the staff by putting in more effort in the

unfreezing stage for these staff to see significant reasons while the current system or process should

be abandoned. A lot of time and resources should be spent teaching and educating the staff with

empirical facts on why the error prone system should be abandoned. References in this process

should be based on the experiences of the staff and not on hearsay to make assimilation faster. The

third and final stage of Lewin’s Change Theory is known as refreezing. Here, the new system is put

in place and has to be adopted as the mainstay throughout the length and breadth of the

establishment. The objective to be achieved by management in this stage is to ensure that the staff

do not revert back to the old model consciously or unconsciously but accepts the new system as the

mainstay and the standard. To achieve this, expectations are set for the staff to follow through

with and operant conditioning can be applied to reinforce the adaptation with the new system using

rewards and punishments. Use of of operant conditioning is rational because the staff has to

understand that using the old model that is pone to errors can cause loss of lives of patients and also

loss of money and time spent answering to lawsuits against the establishment.

General Purpose of FMEA

Failure Mode and Effects Analysis (FMEA) is a structured approach employed in

discovering potential failures and risks existing within the design of a product or process. Failure

modes can be defined as the ways in which a process or a product can fail to achieve desired

results. The general purpose of the FMEA structured approach is to take actions to strike out or

reduce failures, starting with the issues of highest priority. The level of prioritization Is determined

by how serious the consequences of the the failures can be, their frequency of occurrence, and their

ease of detection.
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FMEA approach is also employed for the purpose of documentation of current knowledge and

actions related to the risks of failures to be used in improvement plans. FMEA is used for the

primary purpose of preventing failures by eliminating risks in designs. Subsequently, it’s used in

control, before a process or product is put in use and during the operation time of the process. This

means that the FMEA approach commences at the initial stages of design and runs through the

lifetime of the product or process.

C1. Steps of FMEA Process: There are seven steps in the FMEA process according to the IHI.

Step One: In the step one of the FMEA approach, the process that needs to be improved is selected

and set for analysis. A typical instance of this step in action would be when the establishment I

work with went live with electronic health record. No adverse event had taken place as at the time

of analysis.

Step Two: the next step in the FMEA process involves constituting the team of facilitators that will

oversee the process. The rule of thumb in this step is to chose multidisciplinary professionals to

reflect the inter-professional relationships and inter-collaboration in medicine and health care.

Step Three: Here in the step three the process or product to be analyzed is described in detail. The

constituted team discusses the rules of engagement as well to have all members of the team on the

same page and in tune with the common objective. The team may also consider it important to look

into pertinent areas of the product or the process and also conduct interviews to gain reliable

knowledge and understanding on tje functional state of the product or service. This understanding

will be documented by way of a flowchart.

Step Four: Here, possible problems and risks of failure in the process being analyzed are

identified. The team reviews each step-in process for possible problems and risks of failures in their
ORGANIZATIONAL SYSTEMS AND QUALITY LEADERSHIP TASK 2 10

mode of operation and list them out in the order of priority using how serious the consequences of

the the failures can be, their frequency of occurrence, and their ease of detection as key.

Step Five: After the problems and risks of failures are listed out, the next step is to pick on the

problems topping the priority list made in step four above to work on eliminating. Three categories

of failure modes will be identified in every process or product and they include: likelihood of

occurrence, likelihood of detection, and severity of consequence. These categories of failure modes

are assigned a number 1-10 wherein 1 indicate a failure mode that is least likely to cause harm or

loss of life and the number 10 is assigned to failure modes that is most likely to cause harm or loss

of life.

Step Six: at this step of the FMEA process, the changes discovered to reduce or prevent problems

are designed and implemented. The three failure modes identified in step five above are multiplied

to yield a Risk Priority Number. The RPN indicates the top ten failures in utmost priority in the

process to improve. The process will again be reviewed by adding the Risk Priority Number to each

failure mode.

Step Seven: Here, the success of process changes implemented is measured. The FMEA team

develops measureable and time-specific interventions for failure modes identified in step five to

successfully reduce the RPN for the highest values.

Steps in the Failure Mode Likelihood Likelihoo Severit Risk

Improvement Plan of d of y Priority
Process Occurrence Detection Number
(1-10)
(1-10) (1-10) RPN
Nurse assessment Insufficient or inadequate 7 4 7 196
data collected
(vs, h/w, rx)
ORGANIZATIONAL SYSTEMS AND QUALITY LEADERSHIP TASK 2 11

Md assessment Not reviewing data 2 10 7 140

collected prior to sedating
Diagnostic testing
Md orders medication Wrong dose/ wrong 5 5 10 630
medication
Procedure Notification of 10 10 10 100
staffing: patient 1:1 RN
Post procedure RN 1:1 10 10 10 100
monitoring

Supplemental O2 7 7 10 490
Total
RPN:165
6

C2. FMEA Table

Intervention Testing

The Plan-Do-Study-Act (PDSA) model also known as Rapid Cycle Improvement Model is an

iterative four stage problem solving model used for improving a process, or plainly for carrying out

change. To get the best from this model in the care improvement plan discussed in part B it is

important to include the staff and patients on the evaluation as they can provide feedback about

what works in the new system and what doesn't. I will involve the clients in the process when

feasible because quality in care delivery is defined by their outcome in the establishment.

In applying this approach to test the interventions from the process improvement plan from part B

to improve care, I will start by asking myself three questions:

1.What am i trying to accomplish?

2.How will i know that a change will turn out to be an improvement?

ORGANIZATIONAL SYSTEMS AND QUALITY LEADERSHIP TASK 2 12

3.What changes can i make that will bring about an improvement in care delivery?

The first step I will take is known as the PLAN and would be to assemble the team I will be

working with which would be made up of a group of professional that have knowledge of the

problem or opportunities for improvement in care delivery. Next step is to draft a statement of my

objectives which will be answers to the three questions above. Once this is done, I will brainstorm

with the team on the current system with which things are done in the hospital wherein there is

shortage of personnel and lack of provisions for a staff to be assigned to monitor a patient on

sedation. Next step is known as the DO and involves making attempts to mitigate the root causes of

the problems identified by completing the statement "If we do __________, then __________ will

happen." By so doing, alternatives will be laid out and the one that will best help my team

maximize our resources and achieve our objective. Once this is done, the improvement action plan

would be designed and implemented together with the members of the staff of the establishment.

Data would be collected during this period of implementation to serve as a reference point to be

compared with previous methods. Once this is done, the objective statement will be brought into

the process to help determine in the STUDY stage the way forward by answering the questions

By how much did the plan result in an improvement? /little?

Was the action worth the investment?

Do you see trends?

Were there unintended side effects?

Once we are satisfied with the answers obtained, the next step would be the ACT stage where we

will standardize the improvement plan and commence to use it regularly using the Lewis Change

theory described above. The members of the staff would be encouraged that the PDSA cycle is
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continuous, and the establishment can only become more efficient in care delivery as they adopt the

approach in care planning. become more efficient as they intuitively adopt PDSA into their

planning.

Demonstrate Leadership

Healthcare systems all over the world are faced with the complex challenge of the

provision of safe, high quality, and affordable healthcare delivery to their teaming clients and

patients. It is the priority of the healthcare sector and all the key players and decision makers to

improve and sustain the quality of healthcare services provided. As a result, nurses who are in the

frontline of care as leaders are charged with the task of maximising the use of human and capital

resources available to obtain the best care quality and patient outcomes and also guarrantee

improved health outcomes that will be safe and affordable for the patients. As leaders, nurses are

challenged in their everyday response to duty call with problems that involve human life and

wellbeing which need to be solved with the use critical thinking and continous improvement of

knowledge wealth through lifelong learning. Professional nurse are involved directly in all facets of

a hospital’s quality concerns and their inputs are indisputable. They occupy frontline position in

areas of patient care, medication and bedside management, assistance with major operations,

collecting and reporting medical data and many more.

In addition, it is the responsibility of professional nurses as leaders to monitor and assess patients,

and also perform urgent interventions and rescue operations which will help reduce the risk of or

prevent life threatening health complications. Just like the captain of a football team, professional

nurses oversee other care human resources in the healthcare providers team, which includes patient

care technicians, CNAs, caregivers, LPNs, and more. It does not end here. An attending nurse also

helps in promoting quality care by educating patients and the members of their family on things to
ORGANIZATIONAL SYSTEMS AND QUALITY LEADERSHIP TASK 2 14

know as regards to discharge care planning and also helps contact other support systems a patient

may need such as social services, and others after discharge.

In the present era of value-based care and increased competition among healthcare providers, the

health outcomes of patients are now more important than ever. Improvement in health outcomes of

patients is achievable and of tremendous importance for the survival of hospitals. Nurses

demonstrate leadership in improving patient outcomes by making sure that diagnosis are as quick

as possible and accurate as it is essential for improving patient outcomes. Diagnosis is the

rudiments for proper treatment decisions and nurses as leaders are responsible for coordinating

resources both humans and ,machines to process diagnosis-related patient medical information for

patients in a purposeful and comprehensive way. Nurses make use of modern diagnostic

examinations to increase the quality of the diagnosis upon which treatment are based thereby

reducing cost of care on the downstream sector resulting from diagnostic errors. Nurses also do not

leave the patients to their fate after discharge but also ensure that they only pursue health seeking

behaviors after discharge which will also help improve their health outcomes. Nurses design follow

up appointments and monitoring through communication channels to keep in touch with patients

and always be in the know of the health outcomes of the patients after discharge.

With the level of responsibility accrued to nurses as the largest health care service deliverer, it has

become obvious that as more hospital participate in quality improvement activities increases, the

role of nurses in these activities are also increasing. Nurses are tremendously vital nurses to the

functionality of hospitals and nursing care can be seen as the basic reason why people appear at the

hospital.

No other healthcare professional are better positioned to function on the front lines of quality

improvement than nurses because they are the ones that spend the most time on the bedside of the
ORGANIZATIONAL SYSTEMS AND QUALITY LEADERSHIP TASK 2 15

patients in admission and are in the best position to influence the care delivered to the patients

throughout the length of their hospital stay. As a result, nurses are in the best position to positively

influence improvement outcomes since they know the lapses inherrent in the care they deliver.

Throughout the discussions in this paper I have been talking about a scenario of a care delivery

process cxthat went wrong and how the hospital can improve to prevent a repeat of this kind of

errors. .

The professional nurse leader understands the discrepancies in the care he/she delivers and how it

is error prone. He or she makes use of quality improvement avenues under his/her supervision and

control to study these lapses and coordinate quality improvement efforts to prevent a repeat and

achieve success. In the effort of nurses in influencing quality improvement activities, they inspire

and empower the staff to come forward with their inputs on the challenges they have experienced

int the line of care delivery and how they can be solved. By so doing, they reshape the care delivery

environment to improve quality in care delivery and improve health outcomes of the patients they

serve.

E1. Involving Professional Nurse in RCA and FMEA Processes: Involving the professional

nurse in root cause analysis and FMEA approach to quality improvement and failure prevention are

tantamount to achieving success in these processes. In the sentinel scenario described in this paper

it is the nurses account of the sentinel outcome that will of the basis of judgement in proposing a

new system for the establishment concerned. It is the account of Nurse J knowing that when she left

the room of the patient that patient remained without supplemental oxygen and his ECG and

respiration are not monitored that will make the quality improvement team to understand the areas

they need to look into in making sure that errors like this do not repeat. For this reason Nurse J will
ORGANIZATIONAL SYSTEMS AND QUALITY LEADERSHIP TASK 2 16

be leading the quality improvement team on the areas to look out for and propose plans for

improvement.

References

Institute for Healthcare Improvement (IHI). (2018). PS 201 Root Cause and System Analysis.

Retrieved on August 26, 2018, from app.ihi.org/

ORGANIZATIONAL SYSTEMS AND QUALITY LEADERSHIP TASK 2 17

Jacob, S., & Cherry, V. (2014). Contemporary Nursing: Issues, Trends, & Management. St. Louis,

MO: Mosby. Retrieved from,

https://wgu.vitalsource.com/#/books/9780323390224/cfi/6/72!/4/2/2@0:0