C489 Task 2 overview 7/20

If you look at the Rubric measures and identify the concepts from each, it should help you outline the
paper. It is the concepts or QI tools that you are writing about versus solving or discussing just the
scenario. After presenting the information about the QI concept, you will give the requested example
from the scenario defined in the rubric. Be sure to address the question asked in the Task instructions.
(The order of the sections presented below is based upon the most current version; early versions may be organized
slightly differently but the requirements for your paper’s content are the same)

The concepts you are writing about include:

A. Root Cause Analysis: What is the purpose of the RCA process? What are the main steps in the process?
Identify from the scenario, the errors (causative factors) and hazards (contributing factors). You are
identifying the factors (errors and hazards) that led to the sentinel event. Give a brief overview of the
scenario then speak to the errors made, and hazards contributing to the event.
B. Improvement Plan: Once you have presented all the errors and hazards in Section A, propose one process
change or intervention, which addresses one (or more) area that would reduce the likelihood of the same
outcome for patients.
o You do not need a full RCA improvement plan in scope. (or solve everything that went wrong in
the scenario)
o Examples:
 Time out process to reduce the risk of wrong site surgery now required by JCAHO
 ACLS algorithms to clarify best treatment for different scenarios in the case of Cardiac
or Respiratory emergencies.

B.1 Change Theory

1. Present an overview of Lewin’s change theory; about the human side of change and describe it.
(see QI 201 Lesson1)
2. Give one example of a strategy for each stage that you could use when planning the
implementation of your plan.
C. FMEA: IHI FMEA tool http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx
This pdf talks to the purpose and steps for the FMEA process
How to Cite This Document: QI Essentials Toolkit: Failure Modes and Effects Analysis (FMEA) Tool.
Institute for Healthcare Improvement; 2017. (Available on ihi.org)

This section just applies to your (one process) intervention or change. It is a process that looks at possible
barriers or failures that could interfere with your plan if not considered. FMEA is a proactive versus
retrospective tool.
For the major header, provide a brief summary of what FMEA is and how, once you complete
your plan/intervention or change in process, it will be more likely to succeed. List and briefly
describe each step of FMEA process using the IHI overview tool.
1. Based upon your process change, complete the FMEA table (attached with Assessment
Requirements) giving examples of four steps in your new process, list a corresponding potential
failure for each step. Then apply a 1-10 score for criteria; likelihood of occurrence, detection and
severity of failure, then multiply the rating to determine the risk priority number for each failure
mode. Add the risk priority numbers for the total process risk rating.
2. Your FMEA table MUST be related to your section B, improvement plan

D. Testing Interventions: Propose a specific initial evaluation plan, or pilot to evaluate/monitor whether your
plan would work as you expect before full implementation. The goal would be to have the team evaluate
and modify the plan if needed, first. How many events will you include, who will do it, what data could you
use, over what period of time would the trial last? There is a lot of information in the QI modules about
this. Your pilot must be related to your improvement plan.
C489 Task 2 overview 7/20

E. Give examples for each: improving outcomes, promoting quality care, influencing QI activities.
How can professional nurses demonstrate leadership (influencing change and others) by contributing to QI
processes such as the RCA and FMEA processes?
Why is this an important leadership role for professional nurses?
Why are nurses in a great position to improve operational and care processes?
Some examples:
Actively engage in identifying and resolving recurrent barriers to care.
Participating in teams to evaluate processes.
Share current best practices and new evidence as it evolves.
Role modeling these behaviors to other staff.

 The Cherry text has a great overview of this concept, as does IHI in general, explaining why QI has become
so important. Chapter 22 (latest edition 7): Quality Improvement and Patient Safety
 Another optional site to check out is the ANA website; search NDNQI to read about how nurses are
involved in QI and research related patient safety and improved patient outcomes.

References: For every reference listed, make sure you have a least one in text citation.

Writing Center link for citation help: https://cm.wgu.edu/t5/Writing-Center-Knowledge-Base/How-to-Cite-

Sources-The-Big-Four/ta-p/2199

Sample FMEA Table:

1. Identify the process you listed in section B. One process is easier than 2 or more.
a. Optional to add the name of the process as a sub-title as below
2. 1st Column: List 4 example steps as to how the process is to work, like writing a recipe
3. 2nd Column: Identify one possible way the step/plan could failure for each step
4. Apply (mock) ratings for severity, occurrence and detection
5. Multiply rating to arrive at RPN
6. Add up RPNs for total

Steps in the Failure Mode Likelihood Likelihood Severity Risk

C489 Task 2 overview 7/20

Improvement of of (1–10) Priority

Plan Process * Occurrence Detection Number
(1–10) (1–10) (RPN)
1. Sedation is Order entered 2 5 8 80
ordered in wrong
computer
2.Charge Nurse RN too busy and 6 8 7 336
(CN) Alerted by delays telling CN
RN reviewing
orders

3.On-call Nobody’s on call 5 1 5 25

schedule for the shift
Reviewed by CN
4. CN calls on- Does not reach 3 2 7 35
call nurse to come on-call nurse
in
Total RPN
(sum of all
RPN’s):

476
FMEA Table
Process: 1:1 Staffing for Sedation