C489 Organiational Systems and Quality Leadership

C489 C489OrganizationalSystemsandQualityLeadership SATTask2 WesternGovernorsUniversity OrganizationalSystemsandQualityLeadershipSATTask2 A.RootCauseAnalysis Rootcauseanalysis(RCA)isdescribedawiderangeofapproaches,tools,andtechniques usedtodiscovercausesofproblems.AttimesRCAscanidentifytruerootcausesandsomemore generaloutcometechniques.(AmericanSocietyforQuality,2021).Itwasdevelopedtoprevent predictedharmbyacknowledgingerrorsthatcauseanadverseevent.A1.RCASteps

StepOne:IdentifywhatHappened

Theteammusttrytoaccuratelyandcompletelyidentifywhathappened.Theteamneedsto createarootcauseanalysisofwhathappened.Theteamneedstoorganizechartsanddatatohelp understandthecauseoftheissue.

Steptwo:Identitywhatshouldhavehappened.

Thentheyneedtocheckifotherwayscouldhavebeensettopreventtheoutcomeofthe situation.

Stepthree:Determinewhathappened.

Theteamwillthenneedtoevaluatethescenario’sdatawiththeoutcomes.Ifthereisa negativeoutcome,thenthedataneedstobechangedtopreventanegativeoutcome.Thiswould allowtheteamtoseethesymptomandthecauseoftheissue.

Stepfour:Developcausalstatements.

Thecausalstatementwouldsetthefactsaboutthecurrentconditionsandcontributeto patient’sandstaff’sbadoutcomes.Thisstatementwouldhavethreepartstoit;thecause,the effect,andtheevent.

StepFive:Generatealistofrecommendedactionstopreventtherecurrenceoftheevent.

Thislistwillincorporatemanythingstopreventtheoccurrenceofthesituationathand.It willincludestandardequipment,redundancysuchasdoublechecks,andensuringthatthe processandeducationarecurrent.

StepSix:Writeasummaryandshareit.

Thiswillputtheplantogethertoensurethatrecurrencedoesnothappen.Itwillalso providethedataneededtoshareitwithstaffwithimplementationandoutcome.A2.CausativeandContributingFactors Todeterminethecausativeandcontributingfactorsfromthisscenario,thereneedstobea peerreviewwithmultipleprofessionals,includingtheemergencyroommanager,respiratory therapist,medicaldirector,togooverthefactsoftheincident.Theteamshouldwalkthroughthe eventstepbysteptogetacompletepictureofeachmistake.Thentheyneedtoimplementwhat shouldhavehappened.Mr.Bwasgivenalargeamountofsedationmedicationtomanipulatetheleg manually,andhewasnotputontheappropriateequipmenttomonitor.Mr.Bwasnotona continuousbloodpressuremonitor;theECGwasnotonhim,andhewasnotcontinuously monitoredforoxygenlevel.Theseaspectsofprecautionandmonitoringarehospitalpolicy.

Also,withconscioussedation,thenursemonitorsthepatientuntilheisalertandawake,andthe nursepullsawaytoanotheremergentcase.Whenthenurselefttheroom,thepatient’soxygen levelwasnotbeingmonitored,andaccordingtostaffdataonthatday,therewasenoughstaff,and thatnursetookontoomanyemergentpatients.Togethertheteamwillneedtogoovertheseaspects ofwhathappenedduringthisevent.WhentheLPNresetthealarm,theydidnotnotifythenurse thatthepatient’sstatuswasdeclining.Whentheincomingrespiratorydistresspatientcame,the chargenurseshouldhaveknownthatthisnursehadconscioussedationtohandleandcalledinthe nurse’sbacktocareforthenewpatient.Failuretoalltheseaspectscausedthepatient’slifefor neglectingtheproperstepsofmonitoringthepatientappropriately.B.ImprovementPlan Theimprovementplanforthissituationistoensurethatthestaffneedstoimplementthe rightpolicyandsteps.Thenurseshouldhaveadvisedthechargenursethatsheneededto continuetomonitorthesedatedpatient.TheLPNneedstobetaughtthatthenurse,backupnurse,or chargenursemustbenotifiedifapatientisdeclining.Iwouldensurethatannualcontinuing educationwouldbeimplementedwiththesescenarios.B1.ChangeTheory ThechangetheorybyKurtLewinisbrokendownintothreestepsUnfreezing,change process,andrefreezing.Thefirststepunfreezingencouragesemployeeinvolvementinchangetolay thegroundworkneededwithoutoverwhelmingthestaff.Thestaffwillrecognizethatthereisa problemandwillhelpimplementchangesuchasaprocessinplaceduringconscioussedationto continuemonitoringthepatient.Also,toensurethattheLPNknowswhotoadvisewhenthereisa criticalvalue.Thisstepwillstartwithagroupthatwillthenteachtherestofthestaff.Thesecond stepisthechangeprocessthattheteamwillincorporatethechangeandstartputtingittothetest.Thisgroupwillenforcetheprocessofcontinuedmonitoringandensurethatthenurses

knowwhentoobtainhelpwhenmultiplecriticalpatientscomein.Havingagroupthatispartofthe teamwouldbringlesscontroversysincetheissuehasalreadybeenrecognized.Lastly,thethirdstage wouldbetherefreezingstagewhichwouldbetheperiodofadjustment,andmanagementshouldbe availableduringthistimeforquestions.Forthisscenario,thiswillcanbewhenstaffcanensurethat thedepartmentiscompletelystaffed.Afterthesestepshavebeenimplemented,continuingtofollow upwillbeassessedandthenreassessed.(Raza,2019).C.GeneralPurposeofFMEA ThepurposeofFMEA(failuremodeandeffectsanalysis)istobeaproactivemethodto evaluateaprocessthatwillidentifywhereandhowitmightfail.Italsoassessestheimpactof differentfailurestoidentifythepartsoftheprocessneedingchange.C1.StepsofFMEAProcess ThefirststepoftheFMEAprocessistoidentifytherootcausetoevaluatethesituation.Next,theteamneedstobebroughttogethertoworktogethertooverseetheactivity.Thentheteam shouldmakeacompletechecklistthatmaycomeupinthesituationandneedstobeanalyzed.The fourthstepwillbetodiscoverthecircumstance,reasons,repercussions,probability,intensity, uncertainty,andeffortsofthefailureinthesituation.Theseaspectscanbedoneonthetable.The laststepwillhavetheteamdelegatethenumberofrisksfromthetabletoimproveifneeded.C2.FMEATable FMEATableforYourImprovementPlan*