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A). Explain the general purpose of conducting a root cause analysis (RCA).

1)  Explain eachof the six steps used to conduct an RCA, as defined by IHI.

2)  Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome.

B). Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome.

1)  Discuss how eachphase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan.

C). Explain the general purpose of the failure mode and effects analysis (FMEA) process.

1)  Describe the steps of the FMEA process as defined by IHI.

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.

D). Explain how you would test the interventions from the process improvement plan from part B to improve care.

E). Explain how a professional nurse can competently demonstrate leadership in eachof the following areas:

  • promoting quality care
  • improving patient outcomes
  • influencing quality improvement activities

1. Discuss how the involvement of the professional nurse in the RCA and FMEA processes demonstrates leadership qualities.

Explain the general purpose of conducting a root cause analysis (RCA)

A). Root Cause Analysis (RCA)

Root cause analysis (RCA) provides a framework for comprehensive systematic analysis of a scenario. RCA is defined as process that identifies the basic or causal factor that lead to variation in performance (Charles et al., 2017). The variation in performance lead to undesirable or unexpected outcomes those are adverse. Root cause includes risks or occurrences of a sentinel event that reach a patient that result to permanent harm, death or severe but temporary harm. The root cause analysis focuses on organization systems and processes. The analysis does not focus on individual performance to assign blame but determines process that a team works on with an objective of understanding a process or processes that cause or have potential to cause variations in outcome expected or desired (Brook, Kruskal, Eisenberg, & Larson, 2015). The purpose of RCA is therefore to find the fundamental reason that cause or can lead to failure. The RCA also identifies process change that can be implemented to reduce error and continuously maintain and improve the quality of health care delivery.  

  A1. RCA Steps

The RCA uses a systematic approach to analyze an event that has six steps. Each step build on progressively understanding the cause and identifying what be done in the system to correct and prevent an error from happening (Stang et al., 2018). The first step of RCA is identifying what happened. This step describes what accurately and completely happened. The team organizes and clarifies information that relates to the event to allow visualize what occurred that led to the unexpected or undesirable outcome (Lee, Mills, Neily, & Hemphill, 2014). The second step of RCA is determining what should have happened in an ideal condition. In this step, the team involved in the RCA determines the processes that would have been taken in an ideal condition hence preventing an occurrence of an error in the system. The third step in RCA is determining causes. This step is very important to outlining contributing factors that led to the event. The team “asks why question five times” that enable to look directly to causes and contributing factors in the scenario (Peerally, Carr, Waring, & Dixon-Woods, 2017). The third step therefore outline the root causes of the event by exhaustively question the processes. The fourth step of RCA involves developing a causal statement. The casual statement link identifies causes in step three to effects and then to main event. The causal statements explain how contributory factors are factual to the current situation and how they contribute to undesirable or unexpected outcomes in the healthcare. The casual statements have three parts that are cause, effects, and event. The fifth step of RCA process is generating list of actions that are recommended to change and prevent reoccurrence of the undesirable event. The recommendations are actions that the team thinks that they can help prevent errors from occurring again in the system. The sixth and last step of RCA is writing summary and disseminating findings. This step is important for engaging with other key stakeholders in the process of driving improvement in the system. The RCA process therefore systematically and objectively defines causes that lead to sentinel events

Explain each of the six steps used to conduct an RCA, as defined by IHI

A2. Causative and Contributing Factors

The sentinel events in a sixty-bed rural hospital led to death of a patient. It took seven days and the patient brain was determined dead which was reported by a receiving hospital. Mr. B, a 67-year old, was reported in sixty- bed rural hospital where he was expected to receive primary care and manage his condition. Mr. B was brought to the hospital after tripping was experiencing severe pain to his hip area and (L) leg. Mr. B is assessed in the triage room where he is found to have B/P 120/80, T-98.6, HR-88, and R-32. Mr. B rates his pain at 10 out of 10 using the numerical pain scale. The patient (L) is assessed and is found to be swollen, ecchymosis and has limited range of motion. Mr. B is then taken to emergency department when he is assessed by Nurse J. The nurse assesses the patient medical history that reveals the patient has prostate cancer and impaired glucose tolerance. The nurse also finds that the patient was under mediation for elevated lipids and cholesterol and chronic back pain. After the assessment in emergency department, Nurse J informs emergency department physician Dr. T who proceeds with Mr. B medical examination. The ED doctor orders Nurse J to administer several medications aimed to control pain and sedation. The emergency department receives an energy case at this time where Nurse J is required to attend to the case and places Mr. B on a machine to monitor B/P after every 5 minutes and pulse oximeter. The B/P drops to 110/62 and O2 is 92% and the patient is not offered supplemental oxygen with ECG and respiration not monitored. At this time, the hospital was crowed and Nurse J is fully engaged. After Mr. B was left for approximately 8 minutes, the alarm goes on showing B/P at 58/30 and O2 saturation at 79%. At this point Mr. B was unable to breath and a STAT CODE was called who intervened and resuscitated him. The ECG is back to normal and B/P to 110/70 and with the family wishes Mr. B is referred to a tertiary facility. After one week, Mr. B brain was determined to be dead and the family requested that he be removed from support machine.

In an ideal situation, things should have happened different that would have saved Mr. B life. First, Mr. B should have been provided supplemental oxygen. This would have ensured that the patient O2 saturation is maintained above 90%. Secondly, the patient’s ECG and respiration should have been monitored. Monitoring would have ensured that pulse was continuously assessed and for appropriate action to administer an intervention in case of deteriorating condition. Another idea condition that would have saved Mr. B life is adequate practitioners in the emergency department. This would have helped ease the congestion that was experienced in the department that undermined the patient safety in the facility.

Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome

The root cause of Mr. B life loss was as a result of process failure. The first reason why Mr. B condition worsened is because he was not provided the supplement oxygen. The second “why” Mr. B situation became unmanageable is because the ECG and respirations were not monitored. Another cause of the sentinel event was limited practitioner in the emergency department. These contributory factors worsened the patient condition from a condition that it could have been managed to death of brain cells leading to Mr. B death.

A casual relationship exists among the cause, effects, and the event as recorded in the case study. The lack of supplement oxygen, ECG and respiration monitoring, and over engagement of practitioners in the emergency department led to low B/P reading and O2 saturation that killed the brain cells leading patient’s death.

The following are recommendations to avoid the reoccurrence of a similar event; first, the healthcare should introduce emergency department checklist to ensure all procedures set in the policies are followed when administering health care. Secondly, the healthcare should train all it practitioners for emergency conditions. Another recommendation is that the ED should be allocated more staff to boost it capacity and enhance effectiveness in emergency care delivery.

B).Improvement Plan

An improvement plan is ensure the undesirable event experienced in the sixty-bed hospital energy department does not reoccur or it effects are minimized. The improvement plan consists of stops that will enhance improved health care deliver and safety of the patient. First the improvement plan will involve training more practitioners in the health care on critical care. This will equip staff working in the healthcare to improving quality and safety of patients with critical conditions. The second plan is to allocate more practitioners in the emergency department. This will ensure no congestion is in the emergency department to undermine a nurse ability to attend to a particular critical condition. The third improvement plan is implementing a checklist. A checklist will serve as a cognitive aid to what has to be done in the emergency department to avoid omission. This will ensure no important procedure is left out when providing health care in the emergency department.

B1. Change Theory

Change is important in improving the sentinel event that occurred in the sixty-bed rural hospital emergency department. The improvement plan need to be implemented to ensure there is no reoccurrence of undesirable outcomes that can be prevented (Murray-Davis et al., 2015). Human being naturally dislike change and if not effectively managed can lead to negative impact. The change to improve quality and safe health care deliver will use Lewin’s theory of change. The Lewin’s change theory involves three stages that are unfreezing, changing and refreezing. The first step to change will involve unfreezing status quos, creating need for change and creating awareness of the change goals. This will shape the perception and purpose of implementing improvement plan. In this phase, communication is very important to leaders of change to ensure objectives are known by all staff and they agree on the importance of the change. The second phase will involve implementation of change. This will involve transition to incorporate improved plan in the emergency department. The third and final phase is refreezing and it involves solidifying and stabilizing new processes and activities that are in the improvement plan.

Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome

C). General Purpose of FMEA

The FMEA is a systematic and proactive method that is used to evaluate processes in order to identify area that might fail and assess relative impact (Alamry et al., 2017). One of the purposes of FMEA is to reduce or eliminate failures from a proposed process when implementing change. This helps prevent failure of a process. The other purpose of FMEA is to assess processes and activities in a system and outline the priority according the most in need for change (Reason, 2016).

C1. Steps of FMEA Process

The FMEA process is comprehensive and involves several steps. The FMEA steps are build on the previous one (Chanamool, & Naenna, 2016). The first step is reviewing the process. This involves listing of all components in the process. The second step is brainstorming potential failure modes for each component. The third step of FMEA is listing of potential effect of each failure. This involves impact of failure on the end outcome or subsequent process. The fourth step is assigning severity rankings based on the consequences of failure. The fifth step of FMEA is assigning occurrence rankings that rate severity of effects and uses customized ranking scale. The sixth step is assigning detection rankings that are the chances that the failure can be detected prior to occurring. The seventh step of the FMEA is to calculate RPN with is the severity multiplied by occurrence and detection. The eighth step is developing an action plan that decide and define which failures need to be worked first and who when and what to avoid failure. The second last step of FMEA is taking action that is the implementation process of the finding by the team. The last step in FMEA is calculating the resulting RPN. This step reevaluates each potential failure after the improvement change has been implemented (Askari et al., 2017).

C2. FMEA Table

D). Intervention Testing

The intervention testing will be an important part to assess and evaluation interventions made in the improvement plan. The first improvement plan on the process by introducing checklist in the emergency room will be tested by assess documents used prescribing medication. This will be done by surveying the department to ensure they are using the checklist as a tool that cognitively aid practitioners to remember all important processes in ED. The second intervention of training staff will be tested by checking practitioners’ awarded credential when they complete their training. This will show the topics covered in the training (Runciman, Merry, & Walton, 2017). The last improvement intervention of allocating more practitioners in the ED will be tested by checking attendant lists. This will show how many practitioners were in attendance per day and time in the ED department.

Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan

E). Demonstrate Leadership

Leadership is an important part of an organization system management. Leadership has impact on an organization processes and performance. Professional nurse require leadership skills to lead a team(s) in achieving effectiveness in delivering quality health care (Ouslander et al., 2016). A professional nurse can demonstrate competently leadership in promoting quality care by setting objectives, goals and mission and vision. These enable a nurse to create focus in delivering quality care to patient. A nurse can demonstrate leadership competence in improving patient outcome by setting high quality standards in health care provision. Setting of quality standards will ensure all activities, policies, and processes are aimed at improving patient health care. A professional nurse can demonstrate competency in leadership in improving quality improvement activities implementing effective processes in the healthcare. Effectiveness in an organization processes involve assessing the current process and identifying failures and formulating an improvement plan to enhance patient outcome. The nurse can use RCA to assess variation in performance and apply FMEA to understand what risks are in the processes when implementing an improvement plan.

E1. Involving Professional Nurse in RCA and FMEA Processes

Professional nurse involvement in RCA and FMEA processes is a demonstration of leadership qualities. A professional nurse aim to provide quality health care that can only be achieved by effectively organizing healthcare processes to meet patients’ outcome. A professional nurse involvement in RCA is a demonstration of commitment to finding errors in the healthcare system in meeting high quality health care. This enables a nurse to create an improvement plan for establishing desirable change that promote patient outcome. A nurse involvement in FMEA process is a demonstration of evaluating risk and prioritizing activities when improving processes in health care (Alamry et al., 2017). This demonstrates competence influencing improvement activities in healthcare to meet high standard care for all patients.

Quality leadership enables a healthcare organization to provide high quality and safe health care to patients. Quality leadership refers to effective promotion of health care through influence of quality activities that improve patient health outcome. It is a precondition that is used to implement quality management. Healthcare organizations aim to effectively provide its patients with quality care that is implemented through quality programs led by teams or managers in healthcare (Latino, Latino, & Latino, 2016). The effectiveness of an organization system is dependent on it planning and implementation. An organizational system is a collection of subsystems that are integrated with an objective of accomplishing an overall goal. Organizational systems have several stages that enable monitoring and evaluation to ensure an organization objectives are met by reducing risk and optimizing results. Healthcare organizations credited by The Joint Commission are required to undertake Root Cause Analysis (RCA) whenever undesirable events occur in their system and plan an action to improve their system. The healthcare is then required to conduct failure mode and effects analysis to cause of system failure to reduce the likelihood of the undesirable even occurring again. The following write up discusses the root cause analysis and failure mode and effects analysis a case study of Sixty-bed rural hospital.

Explain the general purpose of the failure mode and effects analysis (FMEA) process

Alamry, A., Al Owais, S. M., Marini, A. M., Al-Dorzi, H., Alsolamy, S., & Arabi, Y. (2017). Application of failure mode effect analysis to improve the care of septic patients admitted through the emergency department. Journal of patient safety, 13(2), 76-81.

Askari, R., Shafii, M., Rafiei, S., Abolhassani, M. S., & Salarikhah, E. (2017). Failure mode and effect analysis: improving intensive care unit risk management processes. International journal of health care quality assurance, 30(3), 208-215.

Brook, O. R., Kruskal, J. B., Eisenberg, R. L., & Larson, D. B. (2015). Root cause analysis: learning from adverse safety events. Radiographics, 35(6), 1655-1667.

Charles, R., Hood, B., DeRosier, J. M., Gosbee, J. W., Bagian, J. P., Li, Y., ... & Hake, M. E. (2017). Root Cause Analysis and Actions for the Prevention of Medical Errors: Quality Improvement and Resident Education. Orthopedics, 40(4), e628-e635.

Chanamool, N., & Naenna, T. (2016). Fuzzy FMEA application to improve decision-making process in an emergency department. Applied Soft Computing, 43, 441-453.

Latino, R. J., Latino, K. C., & Latino, M. A. (2016). Root cause analysis: improving performance for bottom-line results. CRC press.

Lee, A., Mills, P. D., Neily, J., & Hemphill, R. R. (2014). Root cause analysis of serious adverse events among older patients in the Veterans Health Administration. Joint Commission journal on quality and patient safety, 40(6), 253-262.

Makary, M. A., & Daniel, M. (2016). Medical error-the third leading cause of death in the US. BMJ: British Medical Journal (Online), 353.

Murray-Davis, B., McDonald, H., Cross-Sudworth, F., Ahmed, R., Simioni, J., Dore, S., ... & Hutton, E. (2015). Learning from Adverse Events in Obstetrics: Is a Standardized Computer Tool an Effective Strategy for Root Cause Analysis?. Journal of Obstetrics and Gynaecology Canada, 37(8), 728-735.

Ouslander, J. G., Naharci, I., Engstrom, G., Shutes, J., Wolf, D. G., Alpert, G., ... & Newman, D. (2016). Root cause analyses of transfers of skilled nursing facility patients to acute hospitals: Lessons learned for reducing unnecessary hospitalizations. Journal of the American Medical Directors Association, 17(3), 256-262.

Peerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (2017). The problem with root cause analysis. BMJ Qual Saf, 26(5), 417-422.

Stang, A., Thomson, D., Hartling, L., Shulhan, J., Nuspl, M., & Ali, S. (2018). Safe Care for Pediatric Patients: A Scoping Review Across Multiple Health Care Settings. Clinical pediatrics, 57(1), 62-75.

Reason, J. (2016). Using Failure Mode And Effects Analysis To Predict Failure. High Reliability Organizations: A Healthcare Handbook for Patient Safety & Quality, 81.

Runciman, B., Merry, A., & Walton, M. (2017). Safety and ethics in healthcare: a guide to getting it right. CRC Press.

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