The US healthcare system is plagued by challenges that hamper the effective delivery of medical services. While there have been attempts to address these challenges, the fact that they still persist indicates that the attempts have been futile. Staff shortages are one of the most serious problems that ail the system. The practitioners available to attend to the needs of patients often feel overwhelmed. Furthermore, they are forced to work for long hours and under immense pressure. It is not surprising that owing to the pressure that they face, the practitioners often commit errors that can have disastrous consequences. In order to address the problems that the US healthcare system faces, it is important to analyze the root causes. This analysis will reveal the fundamental issues that are to blame for the inefficiencies and general ineffectiveness of the system.
Root Cause Analysis
Root cause analysis is a critical process that facilitates quality improvement in healthcare. Basically, the primary purpose of this process is to identify the problems that underlie the errors and challenges that a healthcare institution faces (“Root Cause Analysis”, 2018). For example, suppose that a hospital has witnessed an increase in the number of hospital-acquired infections. As part of its efforts to address this problem, the hospital conducts a root cause analysis. This analysis reveals that the use of outdated technologies and staff shortages are the root causes of the spike in infections. From this example, it is clear that root cause analysis enables healthcare providers to reveal the underlying issues responsible for challenges being observed. When they conduct root cause analysis, institutions are driven by the need to improve the quality of care that they offer.
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A1. RCA Steps
Root cause analysis (RCA) is a complex and elaborate process that is comprised of a number of key steps. According to the Institute for Healthcare Improvement (IHI), the typical RCA process is composed of six steps. The first step involves defining the event that has happened (“Patient Safety 104”, n.d). At this step, practitioners should gather information about the event whose root causes need to be determined. This step is followed by identifying the ideal situation. Essentially, at this stage, a medical facility describes the situation as it should have happened instead of how it had happened. For example, in the case scenario, Mr. B died after serious blunders committed by the hospital’s hospital. The ideal situation would involve Mr. B receiving treatment for his hip and being discharged. Step three is concerned with identifying the causes of the event that has occurred (“Patient Safety 104”, n.d). Here, a thorough examination is conducted with the goal of pointing out possible causes. At step four, hospitals need to create causal statements that capture the relationship between the adverse event and its causes. Steps five and six are concerned with recommending solutions and creating a summary of the RCA process, respectively (“Patient Safety 104”, n.d). The recommendations that a facility develops should help to address the root causes. By creating a summary, the institution is able to engage in continuous learning and quality improvement.
A2. Causative and Contributing Factors
An analysis of the case scenario reveals a number of causative and contributing factors. In this scenario, Mr. B’s death was the result of such factors as understaffing, poor workflows, lack of adequate oversight and poorly designed medication procedures. The main causative factor is understaffing. In the scenario, it is mentioned that while there was backup staff on standby, on the day of Mr. B’s admission, the hospital was human resources were under heavy strain. In addition to administering treatment and monitoring Mr. B, the nurses were also required to attend to other patients. As a result of their divided attention, they were unable to notice that Mr. B’s condition was deteriorating. The understaffing problem was compounded by the hospital’s poor workflow that made attending to patients difficult. For example, the nurses are forced to abandon Mr. B so as to attend to a patient who had just been brought in. Poor medication procedures are another contributing factor. The nurses and doctors lacked a proper understanding of Mr. B’s medical history and offered medication in amounts that were informed by guesses. That the hospital has not established procedures for ensuring accountability is another contributing factor. Mr. B’s son is assigned the responsibility of monitoring his father. This shows that the hospital had not instituted measures for ensuring that nurses and physicians remained accountable for the welfare of their patients.
Improvement Plan
The death of Mr. B highlights the need for an improvement plan at the hospital. To address the causative and contributing factors discussed above, it is recommended that the hospital should adopt a plan involving activating the standby staff as and when the need arises. The full implementation of this plan will play a critical role in improving quality and reducing incidences of negligence at the hospital. The scenario mentions that the hospital has a team on standby. It can be assumed that this team is in place for situations when the hospital’s practitioners feel overwhelmed. By adopting procedures which stipulate when the standby staff is activated, the hospital will ensure that the available practitioners are able to fully attend to the needs of all patients. This implementation plan involves a number of steps. At the first step, nurses are assigned patients based on the severity of their condition. Patients who are in desperate need of care are prioritized. Step two involves constant monitoring of patient flows to ensure that nurses are able to administer treatment to all employees. If it is determined that the number of patients overwhelm the employees, the standby staff are notified and instructed to join the active workforce. While simple, this three-step implementation process will go a long way in improving efficiency and enhancing quality.
B1. Change Theory
Any change implementation process can benefit immensely from the integration of theoretical concepts and frameworks. Lewin’s model is among the theories that can facilitate the implementation of the improvement plan described above. His model is composed of three important processes: unfreezing, change and freezing (Cummings, Bridgam & Brown, 2016). At the unfreezing stage, organizations abandon the models and processes that they have been using. This stage is critical as it prepares organizations for the implementation of change. For the hospital in the scenario, this step will see it rethink the workflow processes, staff management and patient handling that have defined its operations in the past. At this stage, the hospital will be able to rid itself of the inefficiencies and blunders that caused Mr. B’s death. Change is the next step of Lewin’s model. Here, the organization transitions to the new regime that comes with the change that has been adopted. The hospital will adopt the improvement plan proposed earlier at this stage. The final phase of Lewin’s model is concerned with freezing. Incorporating the change that has been implemented at the second stage is what occurs at the freezing phase. As it follows this step, the hospital should establish a new culture where all practitioners are committed to safeguarding the wellbeing of all patients. The culture should also place emphasis on efficiency and adherence to established guidelines that govern such issues as the administration of medication.
General Purpose of FMEA
However well designed, no improvement plan is perfect. There is always a risk that the plan will fail to achieve the desired outcomes. The failure modes and effects analysis (FMEA) is a tool that helps healthcare providers to anticipate and determine the impact of failures. According to IHI, the FEMA is a “systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures” (“Failure Modes and Effects Analysis”, n.d., par. 1). Essentially, the FMEA fulfills the general purpose of helping providers to prepare for the failure of improvement plans. As they prepare, the providers are able to minimize the damaging effects of the failure.
C1. Steps of FMEA Process
The IHI has developed a 7-step framework for conducting the FMEA process. At the first step, one identifies the process which could benefit from the FMEA process (IHI, 2004). It is advised that individuals should select processes are rather simple and do not come with too many sub-processes. Next, a team that brings together individuals from different disciplines is established (IHI, 2004). All individuals whose support and effort is needed for the successful implementation of the FMEA process should be included in the team. The third step involves conducting team meetings where the steps to be followed as part of the FMEA process are identified. At the fourth step, the team identifies the failure modes and predicts the causes of these modes (IHI, 2004). Here, the team engages in a discussion to determine the problems that may occur and the issues that could cause these problems. With the problems identified, the FMEA process proceeds to the fifth stage where a number of mathematical metrics are determined. These metrics include the likelihood of occurrence, severity and likelihood of detection (IHI, 2004). At stage six, the three metrics are multiplied to obtain the risk priority number (RPN). Step 7 marks the end of the FMEA process. Here, plans for the interventions that will be adopted to improve the process in question are developed (IHI, 2004). The RPN obtained in step six enables the organization to prioritize the processes with the highest RPN.
C2. FMEA Table
The following FMEA tables represents the risks that the hospital in the scenario could face at it attempts to implement the proposed improvement plan:
| Steps | Failure Mode | Likelihood of Occurrence | Likelihood of Detection | Severity | Risk Priority Number (RPN) |
| Assignment of Patients based on Severity of Condition | Patients are not diagnosed accurately leading to poor assignment | 3 | 2 | 9 | 45 |
| Monitoring of Patient Condition and Flow | Data on patient condition is missing | 4 | 5 | 7 | 140 |
| Activation of Standby Staff | Standby staff do not receive activation notification | 2 | 4 | 6 | 72 |
|
Total RPN 257 |
Intervention Testing
After adopting a quality improvement plan, it is important to conduct an evaluation with the goal of determining whether the plan has been implemented successfully. Intervention testing is a process that is useful for evaluation. In an earlier section, it was recommended that the hospital should change its workflow and make more use of the standby staff. This improvement plan promises to fix the numerous issues that the hospital grapples with. As part of the intervention testing for this plan, it is recommended that the hospital should monitor patient condition and seek the feedback of its practitioners. Patient monitoring will help the hospital to determine if the improvement plan has enhanced safety and quality of care. For example, if the hospital observes that nearly all patients are discharged after full recovery, it can conclude that the implementation plan has worked. On the other hand, if such issues as those exemplified by the case of Mr. B persist, the hospital will have a basis to think that the implementation plan has not been effective. Feedback from its practitioners will also provide the hospital with the insights it needs to determine the success of the improvement plan. Suppose that after the plan has been adopted, most nurses and physicians report lower levels of exhaustion, reduced cases of medication errors and general improvements in satisfaction. These positive sentiments will serve as indication that the implementation plan has delivered the desired outcomes.
Demonstrate Leadership
Nurses have a critical role to play in advancing healthcare. They need to understand that they can demonstrate leadership by pushing for reforms that deliver improved healthcare outcomes. There are three areas where nurses can particularly display leadership: promotion of quality care, having an influence on quality improvement initiatives and improving patient outcomes. To improve quality of care, nurses can initiate such actions as using their knowledge to address inefficiencies and pushing for the adoption of cost-minimization programs (Needleman & Hassmiller, 2009). When they take these actions, nurses will be demonstrating their commitment to promoting the quality of care that they offer patients. One of the ways that nurses can demonstrate leadership in influencing quality improvement initiatives is exercising individual responsibility (Draper, 2008). For the quality improvement programs to be effective, the full support of nursing practitioners is needed. Instead of waiting to be instructed, nurses can be proactive and understand that they have a personal mandate to participate in quality improvement interventions. As they seek to demonstrate leadership in improving patient outcomes, nurses can adopt such values as empathy, honesty and listening intently to the concerns that their patients expressed. Furthermore, the nurses can embrace open communication so as to respond to the needs of the patients.
Involving Professional Nurse in RCA and FMEA Processes
In earlier sections, RCA and FMEA were identified as some of the processes that allow hospitals to implement quality improvement interventions. The involvement of nurses in these processes is a demonstration of leadership. As already noted, RCA seeks to identify the fundamental issues that underlie the problems that hospitals experience. When they participate in this process, nurses show that they are not interested in addressing the symptoms of the problems. Instead, they are committed to identifying the root causes and developing permanent solutions. The FMEA process also allows nurses to make it clear that they recognize the importance of permanent solutions and proactivity. Through this process, the nurses are able to identify problems and failures before they arise. Leveraging their leadership competencies, the nurses then implement corrective measures that forestall the failures and problems. In general, the RCA and FMEA processes place nurses at the center of change management. The nurses play active roles that enable them to direct how these processes are implemented and to influence quality improvement.
In conclusion, quality improvement is at the center of nursing practice. Every day, nursing practitioners across the country strive to provide their patients with the best possible quality of care. However, despite the efforts of these nurses, quality and safe care remains elusive. Deeply-rooted institutional failures are primarily to blame for the inability of nurses to offer high quality care. When workflows are not designed properly and hospitals are understaffed, the impact that nurses have on quality improvement is limited. In order to support nurses, medical institutions need to fix institution-level inefficiencies and problems. As they do this, they will allow nurses to function without undue hindrances. Nurses should not wait for organizations to implement change. They should be proactive and impose pressure on policy makers to introduce reforms.
References
10 steps to do a process FMEA. (n.d). FMEA Training. Retrieved November 11, 2018 from https://fmea-training.com/10-steps-process-failure-mode-and-effects-analysis/
Cummings, S., Bridgman, T., & Brown, K. G. (2016). Unfreezing change as three steps: rethinking Kurt Lewin’s legacy for change management. Human Relations, 69 (1), 33-60.
Draper, D. A., Felland, L. E., Liebhaber, A., & Melichar, L. (2008). The role of nurses in hospital quality improvement. Research Brief, 3, 1-8.
Failure modes and effects analysis (FMEA) tool. (n.d). Institute for Healthcare Improvement. Retrieved November 11, 2018 from http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx
Institute for Healthcare Improvement (IHI). (2004). Failure modes and effects analysis (FMEA).
Needleman, J., & Hassmiller, S. (2009). The role of nurses in improving hospital quality and efficiency: real-world results. HealthAffairs, 28 (4). DOI: https://doi.org/10.1377/hlthaff.28.4.w625
Patient safety 104: root causes and systems analysis. (n.d). Institute for Healthcare Improvement. Retrieved November 11, 2018 from http://app.ihi.org/lms/content/f99b4ea2-aeea-432d-a357-3ca88b6ae886/upload/ps%20104%20summaryfinal.pdf
Root cause analysis. (2018). Agency for Healthcare Research and Quality. Retrieved November 11, 2018 from https://psnet.ahrq.gov/primers/primer/10/Root-Cause-Analysis
