Organizational Systems and Quality Leadership

Organizational Systems and Quality Leadership: C489

What is a root cause analysis, or RCA? It is a process used in order to discover the immediate cause of a problem or event. By using RCA’s, the cause of a particular problem can be identified, which in turn can lead to several different systems being used in order to ensure that there are no more occurrences of that particular event or problem.
A1. Explain each of the six steps used to conduct an RCA, as defined by IHI.

Step 1- Identify what happened
Every one that was involved in the incident needs to be able to describe an accurate account of what occurred leading up to the event. The tools that are available in order to help clarify all of the information include time lines and flowcharts. The tools available are used in order to distribute all the information appropriately and ultimately give us a truthful determination of what actually occurred.

Step 2- Determine what should have happened

The team would look at all the information presented and determine what should have happened if all of the steps taken were correct.

Step 3- Determine causes (“Ask why five times”)

The team needs to establish direct factors that contributed to the incident including the direct and indirect causes in this development. The fishbone diagram would be the most advantageous diagram in this step in order to examine and parade all the likely causes of an assured result. There are seven diverse variables that can influence clinical practice and medical mistakes: the task itself, the patient’s traits, the single staff associate, team constituents, labor territory, the institutional setting, and structural and administrative factors.

Step 4- Develop causal statements

The causal statement will aid in showing the cause and effect rapport and then tie it back to the singular event that instigated the RCA. It aids in explaining the primary specifics and circumstances that lead to the poor results. The three parts to this segment include cause, effect, and outcome.

Step 5- Generate a list of recommended actions to prevent the recurrence of the event

The recommendations are variations that will influence the way things are done in the future, in order to avert additional blunders from taking place. There are nine diverse sets that these normally fall into: regulating equipment, guaranteeing superfluity, imposing tasks that tangibly thwart communal errors, physical vicissitudes to the hospital, software apprises, the usage of perceptive advertisements, streamlining the progression, employee training, and generating innovative guidelines and procedures. By utilizing the most resilient act, there tend to be a much larger reduction or even complete eradication of the adverse occurrence.

Step 6- Write a summary and share it

A summary of all the events helps the team members to solidify the actions and steps needed to engage in improvement based off of the events (Institute for Healthcare Improvement, 2015).

A2: Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome.

The first thing you would need to do would be to get everyone who was involved and had direct care or knowledge of the patient, Mr. B, together. This includes the LPN, the emergency department RN, emergency department physician, the hospital quality director, the emergency department manager, the chief nursing officer, and the chief medical officer from the healthcare system.

Mr. B initially arrived at to the emergency department at 3:30pm on a Thursday. He was moaning and complaining of severe pain to his left leg and hip area which started when he tripped over his dog and fell to the ground. His first set of vital signs were stable except for the respiratory rate of 32, which could have been due to him being in severe pain. When asked what his pain level was, he stated to Nurse J that it was a 10/10 on the numerical verbal scale. When Dr. T came in to examine the patient, the patient appeared to be in moderate distress. His left leg appeared to be shortened with edema in the calf, ecchymosis, and limited range of motion. Dr. T is able to stabilize his leg at that time in triage, and then discharged him from triage to a room in the emergency department. He is then admitted by Nurse J, who does an admission history on him and notes that his most recent visit with his primary care physician showed that he has a history of glucose intolerance, elevated lipids and cholesterol, chronic back pain, and prostate cancer. The patient’s current medication use included atorvastatin and oxycodone. Nurse J reported all of her findings to Dr. T, who evaluated the patient and placed an order for 5mg of diazepam IVP for Mr. B. Nurse J administered the medication at 4:05pm, but did not follow the proper sedation protocols her hospital had in place. After several minutes, Dr. T decided that the diazepam did not have the desired effect of muscle relaxation, so he directed Nurse J to give 2mg of hydromorphone IVP, which was administered by Nurse J at 4:15pm. After several more minutes had passed, Dr. T was still not satisfied with Mr. B’s level of sedation, so he orders another 2mg of hydromorphone IVP and 5mg of diazepam IVP, which would have put his total amount received at 10mg diazepam and 4mg of hydromorphone within 20 minutes, all while not being placed on the proper sedation protocols by Nurse J. At 4:25pm, the patient becomes adequately sedated and a successful reduction of the hip takes place and he remains sedated post procedure, which ended at 4:30pm. Nurse J then placed a continuous pulse ox monitor and blood pressure cuff on Mr. B. She was then called to an emergent incoming patient, and proceeded to leave Mr. B with just his son in the room and still not placing him on an ECG. Nurse J should not have left the patient, Mr. B. He was under sedation and it was not safe. If she needed to leave him, she should have called another skilled professional to monitor him so that she could go help with the incoming emergency. Since he was still sedated, he did not meet discharge criteria and Nurse J should have remained at the bedside and provided Mr. B with oxygen, continuously monitored his vital signs with an ECG until they were stable, he was fully awake and alert, able to void, and had no nausea and vomiting. After Nurse J left to help with the emergency that had arrived, sometime after 4:35pm Mr. B’s o2 saturation has a reading of 85% and begins to alarm. The LPN hears the alarm, goes into the room, resets the alarm and does not place Mr. B on supplemental oxygen, and repeats the blood pressure reading without doing any kind of an assessment on the patient or alerting Nurse J to her current findings. The LPN should have immediately alerted Nurse J because this was a change in the patient’s status and what happened in the end could have been ultimately prevented. At 4:43pm, the patient’s son comes out of the room and alerts Nurse J that Mr. B’s monitor is alarming again. When Nurse J enters the room, the blood pressure machine shows Mr. B’s B/P reading is 58/30 and the O2 saturation is currently at 79%. Mr. B is not breathing and no palpable pulse can be detected. A stat code is then called and resuscitative efforts are started. When Mr. B was finally placed on the ECG monitor, it showed him to be in ventricular fibrillation. After 30 minutes of resuscitative efforts, Mr. B’s heart rate returns to normal sinus rhythm, but he is still intubated and completely dependent on the ventilator, his pupils are dilated, he has no spontaneous movements, and he does not respond to any noxious stimuli. His family then requested for him to be transferred to a different hospital for a higher acuity level of care, and he ended up passing 7 days later when all life support is withdrawn per the family’s request.

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

The process improvement plan is a plan that can aid an organization in meeting certain standards of quality measures. This is a systematic tactic which identifies what needs to be addressed, analyzation of the issue, and bettering the current method. An improvement plan for this specific scenario could include that all the staff be educated and trained on the specific policies and procedures directly related to the care they are able to provide in their current jobs. This training should have been mandatory and should be closely monitored by an educator to ensure that those who give direct patient care do so properly. Nurse J should have followed the sedation policy and procedure and stayed with the patient during his sedation, placed him on an ECG, continuous blood pressure, and continuous pulse oximetry monitoring until all of the listed discharge criteria was met. Communication was also largely an issue in this scenario and if Nurse J questioned the medication dosage that was ordered by Dr. T, or the LPN notified Nurse J of the patient’s deteriorating status, this may have been prevented.

B1. 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 theory on the human side of change showed us that organizational change doesn’t have to be multifarious. His theory includes three steps: unfreezing, changing, and refreezing. Unfreezing makes you aware that changes are needed, which in this scenario was evident with the lack of acquiescence of the sedation policy and procedure. The aim of this stage is to bring awareness in order to show that the way things are currently being done are no longer the best practices for the best patient outcome. It is then important to give the staff information regarding the impending change and listen to any concerns they may have, but ultimately state to them why there is a necessity for this change. Then we arrive at unfreezing. Eventually, the staff will become less resistant and accept the change and implement it to their routines as the new normal in the way they do things. Continued efforts and positive reinforcement will help keep this new behavior intact (Nursingtheory.org, 2016).

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

The FMEA was devised in order to categorize the process improvement capacities that are the most important, as well as evaluating and identifying processes that may fail. Each failure that is identified receives a numeric score in order to determine the probability that this failure will continue to occur, which in turns identifies the parts of the practice which are most in need of change. The product of all the scores is given a Risk Priority Number; those numbers are added to gain the overall RPN for the entire process (Institute for Healthcare Improvement, 2015).

C1. Explain the seven steps of the FMEA process.

Step one would be selecting a process to be evaluated. In the scenario with Mr. B, staff education surrounding sedation, policies and procedures, medication management, and patient monitoring should be thoroughly analyzed in order to implement strict courses of action for all patients who are in the emergency department and require a procedure that includes sedation. Step 2 includes assembling a multidisciplinary FMEA group. This should include physicians, RN’s, LPN’s, RT’s, educators, pharmacists, emergency department technicians, as well as management. Step 3 would include gathering everyone that is a part of the multidisciplinary team in order to evaluate all the steps in the process and come to an agreement about them. Step 4 would include the multidisciplinary team identifying all the possible negative outcomes that could occur and then identify all the potential causes of these negative outcomes. Step 5 then includes placing a number on those failures in order to analyze the risk associated with them, in order to (Step 6) give precedence to the areas that need to be evaluated earlier rather than later. Step 7 would then be designating a plan for development. For this situation, the ultimate goal would be to eliminate sentinel events from occurring in patients that are receiving conscious sedation.

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

One of the improvement plans stated in part B was to ensure that all the staff involved in procedures that include sedation, have the proper education associated with the procedure. They should have to be able to show they are competent in that area of learning and have to continue to make evident their competency by having renewal courses. This will build the staff member’s confidence and by having an open and honest conversation about it with them, you will be able to establish a relationship of trust which will in turn give you honest criticism from the staff. This in turn will result in better patient care and more confident staff.

E. Explain how a professional nurse can competently demonstrate leadership in each of the following areas: promoting quality care, improving patient outcomes, and influencing quality improvement activities.

Nurses are the ones that spend the most time with the patients. We are the patient’s advocates. We are a team. We need to work together in order to achieve the goals of high quality care of our patients and their satisfaction. We need to continuously educate ourselves on improvements that can be made and skills that can be improved upon in order to give the patients the best care possible. By working together, more experienced nurses can share their wealth and knowledge with nurses who have just graduated nursing school in order to make them feel more confident in their abilities to care for patients. Some new nurse graduates are in new graduate programs that make doing evidence based practice projects mandatory. By doing this, they are creating new ideas and policies and procedures that can be included in every aspect of care for overall patient satisfaction and improved quality of care, improved patient outcomes, as well as influencing quality improvement activities. Since we are the ones who have the most significant influence on the patient’s overall quality of care, it is absolutely pertinent that nurses get involved in quality improvement practices and let the voices of our patients be heard.

References

Institute for Healthcare Improvement. (2015). Institute for Healthcare Improvement:
Patient Safety 104: Root cause and Systems Analysis. Retrieved October 16,
2018. from https://ihi.org

Nursingtheory.org. (2016). Lewin’s Change Theory. Retrieved October 17, 2018, from
Nursingtheory.org: https://www.nursing-theory.org/theories-and-models/Lewin-
Change-Theory.php