Explain the general purpose of conducting a root cause analysis (RCA).
The root cause analysis or RCA is referred to as a systematic method of determining what is the root cause of an issue and determine the best approach to address such cases. The general purpose of the approach is not to solve the immediate problem, but to ensure that the problem does not recur by eliminating the actual factors that cause the problem exist. In this context, RCA is preventative rather than reactive, since it ensures that the problem being addressed does not occur in the future (Curran, Grimshaw, Hayden, & Campbell, 2011).
Explain each of the six steps used to conduct an RCA, as defined by IHI.
There are six steps when applying the RCA method. The first step is defining the problem. This requires identifying what challenge is being faced. After the problem is identified, information and evidence are gathered. Such information is important when coming up with practical and actionable solutions for the identified problem (Curran et al., 2011). The information and data will then help to identify all the events and issues that contributed to the challenge being faced.
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The next step is determining the root causes of the problem based on the information gathered in the abovementioned steps. The fifth step involves making recommendations for either mitigating or eliminating the reoccurrence of the problematic events. The final step is implementing the solutions for a permanent outcome.
Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome .
The RCA process can be used to solve problems in the health sector. Considering the case of Mr. B, the process can be used to identify the root cause of the patient’s death, despite initial treatments proving to be successful. Mr. B complained of leg and hip pain. The first step was to determine what the problem was by talking to the patient and establishing which symptoms he was experiencing. After this process, tests were carried out to determine the possible causes for the symptoms. Information such as the patient’s vitals, weight, height, allergies, and previous medical history was collected to assist in the diagnosis process. In addition, laboratory tests looked at the cholesterol and lipid levels in the patient’s body. This information is used to inform the nursing staff on which interventions to be used to alleviate the patient’s pain as the root cause of the problem is explored. However, Mr. B became brain dead after treatment and the family requested that he be removed from life support. This required the hospital to find the root cause of the death. After looking at the information concerning the circumstances surrounding the death of the patient. Some of the information that was uncovered was that the nurse was not negligent and the equipment was sufficient for the needs of the patient. Since the death of the patient was a mystery, the RCA model would be invaluable in getting to the bottom of the case, giving closure to the family and protecting the hospital from any liability in case it was not at fault.
The six steps will be followed to determine what caused the event and suggest possible remedies to prevent such cases from occurring in the future. After gathering information about the case, it was clear that the nurse had to leave the patient and attend to two other patients. Despite following all the procedures and acting in a professional manner, the situation where the nurse had to attend to other patients while in an emergency led to the death of Mr. B. Therefore, the solution is better staffing and use of the human resource in the hospital at all times, particularly when emergencies were involved.
Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome.
The hospital has to take proactive measures to ensure that such an event does not reoccur. This is important since it will improve the care outcomes of patients and protect the reputation of the institution. Some of the possible explanations for the scenario include wrong anesthesia dosages, wrong diagnosis whereby the wrong symptoms were treated, and inadequate attention during emergencies due to poor staffing practices. Since the nurse followed all procedures and protocols, the first two modes of failure were unlikely causes. Therefore, the scenario can be avoided if the right staffing policies are used. It is important to ensure that there are dedicated nurses for patients in critical conditions and in the emergency rooms. Since the nurse followed all the due procedure, it is clear that she was not negligent when treating the patient. Therefore, there was a systemic problem, in this case, the use of the nurses on duty. Since the nurse had to attend to other patients while still caring for Mr. B. it is likely that there was a challenge in the staffing and changes need to be made to prevent such issues from occurring in the future. If the nurse was fully engaged with the patient throughout the course of his treatment, the outcome might have been prevented.
Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan.
The Lewin change model has three stages. They include unfreeze, change, and unfreeze. In the unfreeze stage, the company or organization has to agree that change is necessary (Desroches, 2013). This means that the hospital in the case of Mr. B has to accept that is has some shortcoming in its operations or systems. In the second stage, namely change, the hospital has to find a new approach of doing things. This requires addressing the staffing challenges that caused the unfortunate experience of Mr. B. The final stage is refreezing where the staff accepts the new way of doing things. This will involve training the nurses and encouraging them to employ the new system.
Explain the general purpose of the failure mode and effects analysis (FMEA) process.
The general purpose is to determine the potential failures in the design of a process or product.
Describe the steps of the FMEA process as defined by IHI.
The first step is selecting the process for evaluation. This is followed by recruiting a multidisciplinary team and facilitate a meeting between the experts to discuss the case at hand. The team then proceeds to list the causes and modes of failure and each mode is assigned a risk priority number. the results are evaluated and the RPNs are used to create a plan. FMEA is used to create a plan and the impact of the changes are evaluated. Finally, FMEA is used to track if there is improvement.
Complete the attached FMEA table by appropriately applying the scales of severity, occurrence, and detection to the process improvement plan proposed in part B.
Explain how you would test the interventions from the process improvement plan from part B to improve care .
In order to improve care using the FMEA table, the potential interventions would be tested and the outcomes analyzed. One of the interventions was better staffing meaning that dedicated nurses will be assigned to handle emergency cases only while the rest of the staff handles other minor cases (Desroches, 2013). This can be tested by monitoring the recovery rate of the patients in emergency care.
Explain how a professional nurse can competently demonstrate leadership in each of the following areas:
• promoting quality care
Nurse can use their leadership skills to promote the quality of care by being proactive in taking measures to improve care. Instead of being passive, nurses can be on the frontline of ensuring care quality.
• improving patient outcomes
Nurses can improve patient outcomes through leadership by assuming the responsibility of taking crucial decisions, instead of leaving the responsibility to other parties.
• influencing quality improvement activities
As leaders, nurses can make recommendations and suggestions that can be implemented, consequently improving the quality of service.
Discuss how the involvement of the professional nurse in the RCA and FMEA processes demonstrates leadership qualities .
Both the RCA and FMEA are tools used to implement change. Therefore, when a nurse is involved in either process, they are playing a role as leaders since their input will lead to change in the long term.
References
Curran, J.A., Grimshaw, J.M., Hayden, J.A. & Campbell, B. (2011). Knowledge translation research: The science of moving research into policy and practice. Journal of Continuing Education in the Health Professions , 31, 174-180
Desroches, S. (2013) Healthcare providers' intentions to engage in an interprofessional approach to shared decision-making in home care programs: a mixed methods study. Journal of Interprofessional Care , 27 (3), 214-22
