Organizational Systems and Quality Leadership
Organizational Systems and Quality Leadership
- Root Cause Analysis
Root cause analysis (RCA) refers to a structured technique used for the analysis of adverse events in the health care system. Its aim is to determine the main cause of patient harm, undesired patient outcome, organizational system failure, and other serious occurrences (Charles et al., 2016). Thus, the basic tenet of RCA centers on the identification of underlying factors that increase the chance of occurrence of healthcare errors (AHRQ, 2019). This helps to ensure that effective measures are put in place in order to combat the contributing factors. RCA helps to ensure that errors occurring within the health care system are not attributed to individual mistakes. This approach focuses on examination of system flaws (Charles et al., 2016; AHRQ, 2019). In the process of identifying system causes, RCA enables healthcare organizations to understand what actually leads to a given problem rather than just emphasizing on the problem alone.
Initially, RCA was used in the study of the cause of industrial accidents. Today, this method plays a significant role as a tool for detection of safety hazards in the health care sector (AHRQ, 2019). By doing so, RCA helps to improve patient safety. When conducted well, this approach reduces future incidences of adverse happenings. It helps to reduce the cost of the risk (Stafford, 2021). RCA employs the systems approach in studying the cause of both active and latent errors in the delivery of healthcare services to patients. Active errors in this case are those ones that occur due to interaction between complex health care systems and humans. On the other hand, latent errors include various hidden problems in the health care sector or system that result in the occurrence of adverse events (Charles et al., 2016).
A1. RCA Steps
RCA follows a specific protocol to ensure that its objectives are met. This process comprises six main steps:
i.) Identifying what Happened.
In the first phase, the RCA team tries to identify the adverse event that has occurred. Important information about the detected error is collected and thoroughly analyzed for the purpose of determining whether it is factual (Stafford, 2021). The collected information is useful to the team since it helps it to accurately describe what actually took place.
ii.) Determining what should Have Happened
After the identification of what has happened, the team shifts its focus to finding out what might have happened (Stafford, 2021). To get the answer, it is necessary to determine whether the right healthcare procedures were embraced, and whether healthcare providers adhered to them by the way of applying them to their practices.
iii.) Determining the Causes
This stage is in most cases regarded as the heart of the process of RCA. It involves making an attempt to identify various factors that must have contributed to the situation at hand (Stafford, 2021). Both contributory and direct factors are identified. During this process of identifying the causative factors, the team can be guided by this question: “Why did this happen?”
iv.) Developing Causal Statements
Causal statements tend to link the causes of events to their effects. This means that the RCA team should thoroughly understand the main event or actual occurrence. This event can then be linked to its consequences (Charles et al., 2016).
v.) Generating a List of Recommended Actions
At this phase, the team is required to propose various actions that can be used to prevent the reoccurrence of the error (Charles et al., 2016). Some of the actions that can be recommended include standardization of medical equipment, simplification of processes, training of staff members, and development of new policies.
vi.) Writing Summary and Sharing It
This last step involves writing a report about the whole event. The report is then shared with other members of the staff, and facilities. It is important for this report to be written in an easy way in order to ensure that it is well understood (AHRQ, 2019).
A2. Causative and Contributing Factors
There are several factors that cause or contribute to adverse events. They include the following:
i.) Communication Breakdown
Communication breakdown is one of the major causes of medical errors. It affects the flow of information among various health care providers and patients. This results in adverse events (Charles et al., 2016).
ii.) Human Issues
When the set care standards, and health care policies and procedures are not adhered to, human problems tend to become inevitable. An example is poor documentation of the state of a patient (Stafford, 2021).
iii.) Patient-Related Problems
Patient-related problems include those issues that are likely to arise due to poor patient identification, inappropriate assessment of his or her condition, and lack of patient education. Such factors can lead to other serious problems pertaining to healthcare delivery (Charles et al., 2016).
iv.) Healthcare Providers’ Level of Education
Healthcare providers with high academic qualifications are better than those with low qualifications. The latter are more likely to commit errors (Stafford, 2021).
v). Staffing Levels and Patterns
Lack of adequate staffing leads to the overworking of the available workforce. This an open the way for mistakes (Stafford, 2021).
vi.) Technical Problems
Technical problems entail those that are associated with technical failure. Examples include failure of medical devices, and breakdown of equipment (Stafford, 2021).
vii.) Poor Policies
Failures in the healthcare process are sometimes associated with inadequate procedures and poor documentation. All these problems are due to poor healthcare policies (Stafford, 2021).
- Improvement Plan
To avoid the reoccurrence of errors, there is need for healthcare organizations to develop a good development plan that can help to change the situation. This plan should focus on the improvement of healthcare staff capacity, development of a concise protocol to be followed, and putting in place clear healthcare policies. The capacity of the staff can be improved through further trainings that can be effected through workshops and seminar. The trainings can help to increase the healthcare workers’ efficiency (Smith & Johnson, 2019). This can in turn help to ensure that patients get quality healthcare services.
The management of the health care system should also work on coming up with a clear protocol that various healthcare workers can adhere to. This can be in form of setting up standards of care, developing a code of ethics, and putting in place quality indicators. Adherence to these requirements helps to minimize errors in the provision of healthcare services to patients. It enables the healthcare providers to deliver quality and safe services (Finkelman, 2020). This is vital for the achievement of positive patient outcomes.
It is as well important for the management to emphasize on health care policies. The health care policy makers should ensure that they create effective policies that can help to prevent medical errors (Finkelman, 2020; Smith & Johnson, 2019). Such errors cause many unnecessary deaths. The health care management should cultivate the culture of recognizing various safety challenges in time. It should as well try t implement some viable solutions for the challenges. This can be achieved through policies whose goal is to make the delivery of care services to patients safer.
B1. Change Theory
For the proposed plan above to be effectively implemented, change is necessary. According to Kurt Lewin, any meaningful change is one that aims at bringing a lasting change. For this change to be effected, it must be accompanied or motivated by a good reason (Muldoon, 2020). Lewin also observes that change is a process that occurs gradually, and that it should be well planned. It is also important to note that all the people who are likely to be affected by the change must be involved at the planning stage.
Lewin’s theory of change comprises three main sages; unfreezing phase, change phase, and freezing phase (Crosby, 2020; Muldoon, 2020). Unfreezing is the first stage that involves loosening any form of attachment towards a given task (Crosby, 2020). This phase helps healthcare workers to understand why change is necessary. The workers are expected to comply with the changes. Te unfreezing phased can be effected with the help of healthcare manages and the department of education. The healthcare providers need education on an adverse event that has occurred. They also need to understand how the current policies can help to prevent the events of that kind in the future.
Change is the second stage of the theory. This phase entails implementation of new changes by the team that is given that responsibility (Crosby, 2020). The new changes can be in form of new healthcare policies that have been approved by the management. during the implementation of such changes, the management and the team that is entrusted with the task are expected to be available. Their availability helps to ensure that nurses and other healthcare professionals get answers to various questions about the new change.
Freezing is the third and last stage of Lewin’s model. This phase involves ensuring that the new change is well embraced, and that is it effectively implemented in an accurate and consistent manner (Muldoon, 2020). With the successful implementation of the new change, there is a high probability that the propose policies will become part and parcel of the organization. They can play a significant role in ensuring that quality healthcare services are given to patients with various healthcare problems. This can lead to the achievement of better patient outcomes.
- General Purpose of FMEA
Failure Modes and Effects Analysis (FMEA) is a comprehensive tool used for the examination of system failure, and how that failure influences the functioning of the system. In other words, it is a method used to evaluate a given process for the purpose of identifying where it is likely to fail, how it can fail, and the impact of the failure (Simsekler et al., 2019). The objective of FMEA is to ensure that failure is effectively identified before it occurs. This helps to ensure that effective measures are put in place to prevent the failure.
In the health care system, FMEA is used to prevent possible failures by the way of correcting processes in a proactive manner. This helps to curb situations whereby healthcare providers and managers just react to some adverse events due to occurrence of failures. By emphasizing on prevention, FMEA helps to reduce both the staff and patients’ risk for harm (Press, 2018; Simsekler et al., 2019). This is important for the safety of the two parties. It is as well important to note that FMEA is used for the evaluation of new healthcare processes before they are implemented. It enables the healthcare managers to understand how the propose change is likely to influence the existing process.
FMEA enables the implementers of various healthcare products and services to foresee various possible drawbacks, and the associated result. This understanding helps various healthcare providers to ensure that the setbacks are detected and dealt with in time. In the process, the health care system is likely to become robust for the benefit of the various parties it includes (Press, 2018; Simsekler et al., 2019). An example of a major drawback that is likely to be encountered in this case is lack of funds for recruitment of more healthcare providers. This particular failure can be addressed through more financial allocations to the health care sector during the period of budgeting.
C1. Steps of FMEA Process
There are seven major steps in FMEA. These are:
i.) Selection of a Process for Evaluation
This is the first stage of FMEA. It involves defining what is supposed to be evaluated using FMEA, and making a decision on the strategies that can be employed during the evaluation (Press, 2018).
ii.) Recruitment of a Team
This phase involves recruiting an effective multidisciplinary team from diverse background. It is important to ensure that the selected team comprises healthcare professionals with various levels of expertise in the selected area under evaluation. There is need also to appoint a team advisor (Simsekler et al., 2019).
iii.) Convening a Meeting
At this stage, it is necessary to have a meeting in which all the steps that are to be involved in the process are listed and discussed in detail. Diagrams and other visual aids can be used in order to ensure that everybody in the team understands the process well (Simsekler et al., 2019).
iv.) Determining Failure Causes and Modes
Here, it is important to ask the team members to list various modes and causes of failure. This involves listing anything that is likely to cause a problem or interfere with the success of the chosen process. A FMEA table can be used to make this work easier (Press, 2018).
v.) Rating Risks and Assignment of Risk Profile Number (RPN)
At this stage, the various risks for failure are detected and ranked according to their severity. After this, the risks are given a RPN. This number is calculated through the multiplication of the related scores within the FMEA table (Press, 2018).
vi.) Making a Decision on the Course of Action
This particular phase involves making important decisions about what actions are to be taken in order to mitigate the risks. Majority of the actions can center on how to lower the likelihood of the reoccurrence of a certain failure (Simsekler et al., 2019).
vii.) Documentation of Results
This is the last phase or step of FMEA. It involves the documentation of all the FMEA results in detail. The documented results are important for future references (Simsekler et al., 2019).
C2. FMEA Table
NOTE: See the attached table.
- Intervention Testing
The plan-do-study-act (PDSA) model can be used to test interventions for the improvement plan recommended earlier on. This can be done as follows:
i.) Plan
This is the first phase of the model. Planning in this case starts with the process of assembling a suitable team for the set task. After this, it is necessary to come up with the goals or objectives of the planned change. From here, the team can then describe the adverse event at hand in detail. It is also important to determine the causes of the problems, and what can be done to alleviate them (Crowfoot & Prasad, 2017).
ii.) Do
After planning, next is the step of doing. Here is where the implementation of the intervention begins. This phase starts with the collection of relevant data for the evaluation of the plan. To make the work a bit easier, the team may find it necessary to use flowcharts, check sheets, and other materials to show the frequency of various occurrences over time. This information is essential since it can be used to determine the magnitude of the happenings (Melnyk & Fineout-Overholt, 2019).
iii.) Study
This stage entails evaluation of the implemented intervention in order to determine whether its objectives are met. For instance, the team can determine whether the intervention brought any form of improvement. It is as well important to find out whether the implementation of the intervention was associated with certain trends. Additionally, the team has the responsibility o determine whether this intervention resulted in some unplanned side effects (Crowfoot & Prasad, 2017; Melnyk & Fineout-Overholt, 2019).
iv). Act
The fourth and last stage involves taking an action. The best way through which this can be accomplished is through reflecting on the planned intervention and the associated outcomes. This is necessary for the purpose of finding out whether the intervention was successfully implemented or whether its implementation was a failure. The team can celebrate any achievement or improvement. It can as well learn from various lessons learned in the course of implementing the intervention (Crowfoot & Prasad, 2017; Melnyk & Fineout-Overholt, 2019).
- Demonstrate Leadership
There are many ways through which a professional nurse can demonstrate leadership skills in promoting quality improvement. To begin with, a nurse leader should inspire and encourage others (Hassmiller & Pulcini, 2020). This can help to ensure that the common goal of a health care organization is achieved. An effective nurse leader has to serve as a good example to his or her followers (Hassmiller & Pulcini, 2020). This is important given the fact that just like in other professions, the nursing workforce requires some role models who can be emulated.
A nurse who is in a leadership position is expected to create a cohesive work environment (Hassmiller & Pulcini, 2020). In order to achieve this, the leader should encourage those who follow him or her to embrace team work. This approach is important when it comes to interprofessional collaboration in the provision of care services. A good nurse leader should promote effective communication among team members (Hassmiller & Pulcini, 2020). The best way through which this can be effected is by ensuring than formation is freely and openly shared among the followers.
It is also important to note that any effective leader in the profession of nursing is one who is able to solve various conflicts involving those who are under his or her leadership (Murray et al., 2017). This can help the team members to have a good working relationship among themselves. Moreover, a good leader in nursing should be open to change (Murray et al., 2017). Nursing practice keeps on changing from time to time. Therefore, nurse leaders must be in the forefront in accepting this change.
E1. Involving Professional Nurse in RCA and FMEA Processes
Nurses play a critical role in enhancing quality improvement within health care organizations. This is due to the fact that they serve as the connection between health care organizations and patients. Therefore, it is important to involve them in RCA as well as in FMEA. Nurses are equipped with critical thinking skills. They make important judgments in their practices. As a result, they can be used in the identification of the cause and affects of an adverse occurrence (Murray et al., 2017; Hassmiller & Pulcini, 2020). The process of collecting information from patients, their family members, and other healthcare workers requires integrity and honesty. Many nurses possess these skills. Therefore, they can be used to collect the data (Murray et al., 2017; Hassmiller & Pulcini, 2020).
Unlike in the past, nurses are today increasingly being regarded as importance decision makers in the health care system. They use the evidence that is available in making vital judgments pertaining to the diagnosis and treatment of patients (Murray et al., 2017). A professional nurse can be an important role model to others. He or she can as well be a mentor. Due to these abilities, a nurse can be at a position to understand why change is often resisted among the peers (Hassmiller & Pulcini, 2020). If possible he or she can do everything in order to ensure the core workers are motivated to accept the set change for their own benefit.
References
Agency for Healthcare Research and Quality (AHRQ). (2019). Root Cause Analysis. Retrieved from https://psnet.ahrq.gov/primer/root-cause-analysis
Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., Biermann, J. S., & Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient Saf Surg., 10 (20). doi: 10.1186/s13037-016-0107-8
Crosby, G. (2020). Planned Change: Why Kurt Lewin’s Social Science is Still Best Practice for Business Results, Change Management, and Human Progress. Milton: Productivity Press.
Crowfoot, D., & Prasad, V. (2017). Using the plan–do–study–act (PDSA) cycle to make change in general practice. J R Coll Gen Pract, 10 (7): 425-430. https://doi.org/10.1177/1755738017704472
Finkelman, A. (2020). Quality Improvement: A guide for integration in nursing. S.l.: Jones & Bartlett Learning.
Hassmiller, S. B., & Pulcini, J. (2020). Advanced Practice Nursing Leadership: A Global Perspective. Cham : Springer.
Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia : Wolters Kluwer.
Muldoon, J. (2020). Kurt Lewin: Organizational Change. Cham: Palgrave Macmillan. https://doi.org/10.1007/978-3-319-62114-2_32
Murray,M., Sundin, D., & Cope, V. (2017). The nexus of nursing leadership and a culture of safer patient care. Journal of Clinical Nursing, 27 (5-6):61287-1293
Press, D. (2018). Guidelines for Failure Modes and Effects Analysis for Medical Devices. London: CRC Press.
Simsekler, M.. C. E., Kaya, G. K., Ward, J. R., & Clarkson, P. J. (2019). Evaluating inputs of failure modes and effects analysis in identifying patient safety risks. International Journal of Health Care Quality Assurance, 32 (1): 191-207. https://doi.org/10.1108/IJHCQA-12-2017-0233
Smith, C. M., & Johnson, C. S. (2019). Preparing Nurse Leaders in Nursing Professional Development. Journal for Nurses in Professional Development, 35 (4): 222-224. doi: 10.1097/NND.0000000000000540
Stafford, T. (2021). Developing an Effective Root Cause Analysis. Retrieved from https://www.performancehealthus.com/blog/developing-an-effective-root-cause-analysis
