Organizational Systems and Quality Leadership

Explain each of the Six Steps Used to Conduct an RCA, As Defined by IHI (IHI, n.d) 

The general purpose for conducting /carrying out an RCA process is to allow the identification of systems and processes’ breakdowns which led to the event (Dale and Curtis, 2014). It answers the following questions; what occurred, why it occurred, and what to be done to avoid its reoccurrence. 

According to Dale and Curtis (2014), the following are the steps used for conducting and RCA: 

Identification of what happened. 

This is the first step of the RCA process and it must be done exhaustively and accurately. The success of the step is facilitated by teams’ formation and incorporation of diagrams to enhance clarity. 

Determination of what should have happened. 

This step involves the analysis of the cases presented to help generate to be done. 

Causes determination. 

This allows for the identification of various factors with direct involvement in the development of the problem/condition. During this step, experts are included in the process and diagrams like Ishikawa are utilized. 

Generation of recommended actions to ensure that the problem does not occur again. 

This involves drawing up a list of recommended actions under a number of categories to ensure the categories range is broad enough to enable the accommodation of an optimum number of changes. 

Writing a summary and sharing it. 

Finally, the summary of the whole RCA process is made and distributed among stakeholders. 

Apply the RCA Process to the Scenario to Describe the Causative and Contributing Factors that Led to the Sentinel Event Outcome. 

Identification of what happened. 

In the provided scenario, it is clear that the patient, Mr. B was given an overdose of both hydromorphone and diazepam and yet he was already under oxycodone (an opioid). The interaction of these drugs produced severe effects including the ventricular fibrillation that occurred post-surgery which was caused by the hydromorphone overdose. Other severe side effects as a result of the combination of these drugs include brain death and breathing problems. The age and the fragile nature of the patient’s health at that particular time increased the chances of developing undesirable outcomes. His death was caused by a combination of the opioid medication, withdrawal effects of the sedatives, and his health status. 

Determination of what should have happened 

Dr. T and nurse J should have had a thorough review of Mr. B’s medical history prior to putting him on sedatives and at least not that heavily. This would have enabled them to opt for sedatives with fewer side effects and this would have saved Mr. B’s life. 

Determination of the cause. 

Deterioration of the patient’s health and the eventual demise occurred as a result of heavy administration of the sedative drugs ( hydromorphone and diazepam) whose side effects range from heart effects to respiratory problems. The complications worsen when these sedatives interact with opioids like oxycodone therapeutically. The effects of the withdrawal were too much for the patient given his age and health status. 

The recommended actions list. 

The first action is to create a cognitive aid checklist with all the procedures that are performed while undertaking the patient examination. This will prevent the reoccurrence of such problems. This should be followed by the creation of policies that will ensure the aids are put into use by all healthcare providers. 

B. Propose a Process Improvement Plan that Would Decrease the Likelihood of a Reoccurrence of the Scenario Outcome. 

For this scenario, an appropriate process improvement plan is generating standard operating procedures that will provide guidance to the healthcare providers in review the patient’s medical history in order to ensure such a scenario does not reoccur. 

Discuss How Each Phase of Lewin’s Change Theory on the Human Side of Change Could Be Applied to the Proposed Improvement Plan. 

Unfreezing Stage 

This represents the first stage of Lewin’s analysis where the change focus is identified. This will involve establishment and implementation of procedures (SOPs) which will ensure that clinicians thoroughly review the patients’ medical history before putting on medication. The step involves communication among stakeholders which include administration, managers and healthcare providers. The scenario shows a number of loopholes especially in the assessment of the patient and improvements are needed to prevent such cases from occurring again. Formation of a team that includes healthcare providers and various experts within the field and the process is identified. 

Moving Stage 

This is the phase of actual change where the change is planned and implemented. Implementation of the standard operating procedures to review patient’s medical history the chances of such scenarios are minimized. This can be sustained through corporation among stakeholders which include nurses, administrators, nurse educators, and program managers to enable them to introduce and use enhanced clinical information systems and information technology . This facilitates the review of existing policies and identification of loopholes and gaps that contributed to the problem. This leads to anxiety among employees as they anticipate job loss or being sent for further training. 

Freezing or Refreezing Stage 

This represents the final stage of Lewin’s theory where the change takes place. It ushers in a period of stability and evaluation. It is in this phase that all the suggested or intended changes are implemented and this will make the employees anxious as they are at risk of losing jobs or the introduction of a new routine. The employees will, however, embrace the changes by considering its benefits to them and even those who will be reluctant will have to understand that they have to do things differently henceforth. This involves the introduction of measures that will ensure strict adherence to the process. These measures may include the creation of policies, employees’ training, and supervision. 

C. Explain the General Purpose of the Failure Mode and Effects Analysis (FMEA) Process. 

The general purpose of the FMEA is to implement actions that lead to the elimination or minimization of the failures beginning with the highest priority to the lowest priority. FMEA is utilized in designing to ensure no failures occur. Additionally, it is used a control prior to and during ongoing process’ operations. 

Describe the Steps of the FMEA Process as defined by IHI. 

Multidisciplinary team recruitment 

This is a team comprising of individuals involved at any phase of the process. 

Team meeting to outline all the process’ steps 

All team members should be accorded an opportunity to contribute on the process steps and this may require a few days to be accomplished as clear and specific steps are listed. This may include the use of diagrams to ease the work. 

Failure modes and causes are listed by the team 

This involves the identification of possible failure modes as well as the possible causes of failure. Factors which might cause failure are listed and appropriate solutions are put in place. 

The team assigns a numeric number to each failure mode 

This assists in prioritizing the actions as factors including severity, detection, and occurrence are considered. 

Results evaluation 

This involves calculating the risk priority number (RPN) which is obtained by multiplying the severity and the likelihood of occurrence and detection together. The sum of all the findings gives the RPN of the whole process. 

Process improvement efforts are planned using RPN 

An action plan that will cater for the above factors is hutched depending on the results. 

D. Explain How You Would Test The Interventions From the Process Improvement Plan From Part B to Improve Care. 

The interventions may be tested by gathering the team which includes a quality improvement member in order to plan on rolling out the change (Dale and Curtis, 2014). The initial rollout has to be a small scale involving a single unit of the facility and for this scenario, the ideal unit is the emergency department. The members of the staff in the team participating in the testing the intervention are given education on their responsibility and the components of the test. An update of the continuing education by any nurse or member of the team participating in the actual testing process is carried out. Once the team members have received this education, a date is set when the staff will use the SOPs/checklist. The use of the SOPs is analyzed and a meeting with the team tasked with the implementation of the change. The meeting will allow for the discussion and implementation of the achieved success, failures encountered, and the required modifications. In case modifications/changes are required the staff is retrained/re-educated. The cycle is repeated until satisfaction is attained through the implementation team. After this, the intervention which is the use of SOPs/checklist is expanded to other units or departments within the hospital especially where conscious sedation is done. 

E. Explain How A Professional Nurse Can Competently Demonstrate Leadership in Each of the Following Areas: 

Promoting Quality Care 

Nurses have the potential to showcase their leadership qualities through the promotion of quality care by ensuring that the standards of quality care are raised. This can be achieved through the creation of policies aimed at ensuring that healthcare providers adhere to the set standards as well as participate in research and strategic planning. 

Improving Patient Outcomes 

As a leader, a nurse can play a major role in the improvement of patient outcomes by ensuring that other nurses understand how important their role is in upholding patient well-being. Creating policies aimed at improving nurses’ relationship with patients will aid in improving patient outcomes (Weiss and Tappen, 2014). 

Influencing Quality Improvement Policies 

As a leader nurse, undertaking both quantitative and qualitative research equips the nurse with first-hand information that may be important in influencing the policy changes (n.d). Additionally, nurses can demonstrate leadership qualities by participating in policy-making processes which increases the chances of giving patients quality healthcare. 

Discuss How the Involvement of the Professional Nurse in the RCA and FMEA Processes Demonstrates Leadership Qualities. 

Involvement of the nurse in RCA and FMEA processes, allows them to contribute to handling the processes within healthcare set up (Weiss and Tappen, 2014). RCA and FMEA are used to identify ways which can help improve nursing as a practice. Nurses’ involvement in these processes gives them an opportunity to actively take part which changes the ways in which healthcare can provide. Technically, nursing leadership involves the ability to detect and identify problems, prioritize them and effectively solve them which makes the two processes a perfect demonstration of leadership in nursing. 

References 

Dale, C., & Curtis, J. R. (2014). Quality Improvement in the intensive care unit. In The Organization of Critical Care (pp. 87-107). Springer New York. 

Institute for Healthcare Improvement. (n.d). Root Cause and Systems Analysis (Publication). 

Weiss, S. A., & Tappen, R. M. (2014). Essentials of nursing leadership and management. FA Davis.