Organizational Systems And Quality Leadership Task 2 PDF

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C489 Organizational Systems and Quality Leadership SAT Task 2 Elizabeth Ripp Western Governors University Molly Hall

Updated: 12/11/20

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Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis Root Cause Analysis (RCA) is the methodology of reviewing and identifying an adverse event within the health care system and the steps that led to the event. The purpose is to identify what happened, when did it happen, how it happened and why it happened. This approach does not focus on the who and does not look to place blame on an individual but instead investigates the whole system to find the processes that could have led to the outcome. This process or tool will also explore what can possibly be done to prevent the adverse event from happening again. (IHI, n.d.) A1. RCA Steps There are 6 steps within the Root Cause Analysis (RCA) tool assessment. Step 1: Identifying what occurred The team will evaluate the event and determined what occurred. Visual aids such as flow diagrams are useful to identify what happened prior, during and after the event. Step 2: Determine what should have happened The team will identify what would be the ideal outcome and the steps needed to achieve that outcome. Again, a visual flowchart of step-by-step process can be helpful to review what is needing to be completed to obtain the goal. Step 3: Determine the causes The team will “ask why 5 times” to determine or diagnose the most reasonable or pertinent facts for the causation of the adverse event instead of focusing on the “individual symptoms” of the adverse event. A fishbone diagram is helpful visual tool to group the “symptoms” for a larger picture. Updated: 12/11/20

3 Step 4: Develop causal statements The team will develop statements that will link the cause determined in step three to the outcome and back to the adverse event that prompted the RCA. The three components of the statement will consist of the cause, the effect, and the actual event. Step 5: Generate a list of recommended actions to prevent the event from transpiring again The team will identify suggested activities for process improvement to prevent the adverse event from occurring again. Examples include organizing resources and making them readily available, hard stops that block employees from errors/ missed steps, revising or upgrading technology, clarifying procedures and workflows, increasing staff education and trainings, and implementing new policy strategies. Step 6: Create a summary and distribute it Within this last step, the team will summarize the adverse event and outline the recommendations or new procedures to be implemented to prevent like events from occurring again. Flow charts of the new steps are helpful to add visual clarity to the change in process. A2. Causative and Contributing Factors The first error to occur within the scenario of Mr. B’s hospital experience was that the protocol for conscious sedation was not adhered to. Mr. B presented to the emergency department in moderate distress with increased respirations of 32 and a pain rating 10/10 on the verbal numerical pain scale. Despite the evidence of increased respirations, the oxygen saturation level was not identified upon admission. According to the hospital policy, prior to starting the conscious sedation protocol of administering intravenous medication, the nurse should have continued to monitor the patient, provide oxygen therapy, and initiate continuous vital signs and ECG monitoring. This may have been due to the nurse lacking knowledge of the medication

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4 onset, peak, and duration. Hydromorphone, when administered intravenously, reacts within five minutes, has a short peak result time of ten to twenty minutes and a short half-life of three to four hours. Diazepam acts within one to three minutes of intravenous administration and has lasting effects of greater than twelve hours (Lexicomp, 2016). Mr. B was given too much sedation within a short period of time. In just 20 minutes, Mr. B. was given a total of 10 mg IVP of diazepam and 4 mg IVP of hydromorphone. These sedative medications also have a side effect of causing the patient to become hypoxic which indicates the need for continuous blood oxygen saturation monitoring and supplemental oxygen placement. Another subsequent error that occurred was that the LPN acknowledged the alarm for low oxygen saturation but instead of notifying the RN, reset the alarm and repeated a blood pressure and was then occupied with other patients. The LPN may have been overwhelmed with the increase of patients within the Emergency Department waiting room, being triaged/ admitted and new orders/ tasks needing to be completed. The Emergency Department seemed to be to then be experiencing a staffing shortage. The scenario reports that Respiratory Therapy was in-house, and that additional staff were available as needed but was never requested to help monitor Mr. B or with additional tasks. Sufficient equipment was also available and in working order but was not activated. A lack of knowledge and failure to communicate concerns may have led to the subsequent STAT code which was called and the horrific details that ultimately led to Mr. B’s death. B. Improvement Plan

The first step in the improvement plan is to formulate a team or professionals from different aspects of the patient care spectrum. Members of this team would include the medical

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5 director, director of nursing, the Emergency Department manager, an expert in risk management, staff nurses and respiratory therapy professionals. Once the team is formed the root cause analysis (RCA) will be systematically identified and strategic measures will be implemented for quality improvement to ensure this scenario does not reoccur. The team will meet several times at consistent intervals to gather data. The first step in the RCA will be to create a flow chart of all the critical facts that occurred prior, during and after the adverse event that Mr. B experienced. This can be obtained from interviewing hospital staff and Mr. B’s son. Review of the medical record is also a source of pertinent information. Next a second flowchart can be formulated of the correct steps of what should have happened under ideal circumstances to ensure positive outcomes for Mr. B. This flowchart can then be visually compared to the initial flowchart and leading to the third step of the RCA. Within the third step, the “five whys” will be asked to obtain a full understanding of why this happened to Mr. B. The creation of a fishbone diagram will help present the visual of the systematic failure as a whole instead of focusing on the individual actions of one staff member. The focus is not on the “who” but on why the system failed. The fourth step the team will embark on is to develop causal statements including the cause, result of the cause, how they each correlate to each other leading to the actual event. These causal statements must be easy to understand but also detailed. Within the fifth step, the team will develop solutions to implement to prevent the reoccurrence of the event from happening again. Lastly, the team will summarize the RCA and disperse among the hospital community. Based on the scenario presented with Mr. B, this writer would recommend further education and training regarding the conscious sedation protocol, implementing a hard-stop within the medication administration record for the quantity of sedation medication administered within certain timeframes, and gathering full sets of vitals including a pulse oximetry upon the

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6 triage process when patients present to the Emergency Department. This writer would also recommend monitoring the patient admission, acuity, and flow at set interval to ensure appropriate staffing is available to decrease the sense of compassion fatigue, nurse burnout and feelings of being overwhelmed by tasks needing to be completed. B1. Change Theory In 1950, Kurt Lewin introduced a three-step process to implement change. This is also known as the unfreezing-change-refreeze model. Within the unfreezing stage, a method must be found to dismantle the inefficient procedure. The second stage involves enabling the change required to promote positivity. Lastly the third stage of refreeze, is the process of repetition and turning the change into a habit. This habit will now become standard operating procedures. (Lewin’s Change Theory, 2020) Reviewing the scenario involving the actions that ultimately led to Mr. B’s death, the ED managers and inpatient education team will inform the hospital staff of the problematic steps taken and why these steps are precarious. Next data will be presented to staff to promote changes such as compiling medication checklists, continuous vital sign monitoring, hard-stops within the conscious sedation protocol, and utilization of back up staffing. In the third stage or refreezing stage, the team will continue to monitor and implement the new policies and procedures to become standard operations and second nature to the staff. By the new positive changes taken becoming normalized by staff, the likelihood of a similar scenario happening again becomes greatly decreased. C. General Purpose of FMEA Failure Modes and Effects Analysis (FMEA) is a method capitalized to identify potential failures or defects that may materialize. It is a preventative and proactive approach taken by a

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7 multi-disciplinary team, for evaluating a system to find areas that possible harm can occur. The team will focus on the steps of the process, failure modes or what could go wrong, failure causes or why would the failure occur and failure effects or consequence. (IHI, 2017) C1. Steps of FMEA Process The first step for the FMEA process is to determine a subject to assess. The second step is to create a multi-disciplinary team to manage the effort. During the third step, the team will mutually formulate a list of all the stages that comprise the process needing review. The fourth step will be highlighting the circumstances, causes, repercussions, likelihood of occurrence and detection, intensity, uncertainty, and efforts of the failure within the FMEA table. Step five will involve concluding the risk priority numbers (RPN) to the failure modes. The higher the score number, the more proactive the team will be to prevent the failure mode. The sixth step will be a time for the team to consider the future effects and modifications needed. The final step is for the team to monitor and scrutinize growth using RPN and designated objectives. C2. FMEA Table See Additional Document D. Intervention Testing The plan-do-study-act (PDSA) cycle is an effective tool to test process changes and monitor improvements within the healthcare setting. The PDSA cycle will identify improvement plan, a team will pilot the interventions and study the outcome. Finally, if successful results are proven, the plan will be put in to action by the rest of the healthcare system. An example of an improvement plan documented in section B of this paper is to include a hard-stop system within the electronic medication administration record to avoid giving too much conscious sedation medicine within a certain timeframe. A checklist would also be created containing the necessary

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8 steps such as continuous vital sign monitoring, sedation checklists, staffing / patient flow number and utilization of float pool staff. Surveys will be conducted on a small group of staff volunteers over a 3-week period. Input obtained will be used to identify the changes needed and the effectiveness of the alterations. Chart audits and incident reports will be analyzed for checklist utilization, positive patient outcomes and satisfaction. The team will study the results to review if additional changes need to be made in monthly meetings. Once the new methods are deemed satisfactory, an improved standard operating procedure will be deployed to the rest of the organization. E. Demonstrate Leadership Professional nurses are influential in promoting quality care and safety of patients within healthcare settings. According to the American Nurses Association (ANA), “The nurse promotes, advocates for, and strives to protect the health, safety, and right of the patient” (ANA, 2015). Nurses are at the frontline providing direct patient care and partaking in evidence-based research for identification of the most current best practices. Nurses that demonstrate leadership are knowledgeable in identifying process failures, facilitating team coordination to brainstorm process improvement, and conducting test trials, unbiased review of results and distribution of updates to the rest of the staff. Nurses can also demonstrate leadership by leading by example and following hospital procedures and holding oneself accountable for actions. Above all, nurses are held to a higher standard by performing to their best and providing exceptional patient care. E1. Involving Professional Nurse in RCA and FMEA Processes Nurse involvement in RCA and FMEA Processes allow for viewpoints from direct patient care to be explored and shared. Active participation will lead to further empowerment and courage to voice concerns, requests, and recommendations to upper management. Nurses can

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9 also provide an illustration of a whole patient care scenario instead of just one incident due to the participation in the continuum that comes from providing direct patient care. One of the top priorities of being a nurse is to promote patient wellbeing and safety and what better way to do that then participate in a quality improvement project.

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10 F. Sources American Nurses Association (ANA). 2015. Code of Ethics for Nurses. https://www.bc.edu/content/dam/files/schools/son/pdf2/ANA%20code%20of %20ethics.pdf

Colin, J.L. McCartney, Ahtsham Niazi. (2006) Use of opioid analgesics in the perioperative period. Retrieved from https://www.sciencedirect .com/topics/medicineanddentistry/hydromorphone Colin, J.L. McCartney, Ahtsham Niazi. (2006) Updated: 12/11/20

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Use of opioid analgesics in the perioperative period. Retrieved from https://www.sciencedirect .com/topics/medicineanddentistry/hydromorphone Diazepam. In: Lexi-drugs online [database on the Internet]. Hudson (OH): Lexicomp, Inc.; 2016 [updated 6 Jan 2016; cited 10 Dec, 2020]. Available from: http://online.lexi.com. Subscription required to view Institute for Healthcare Improvement. (n.d.). Patient Safety 104: Root Cause and Systems Analysis. https://srmc.na60.content.force.com/servlet/fileField?id=0BEc000000LYai. Institute for Healthcare Improvement. (2021). Plan-Do-Act-Study (PDSA) Worksheet. http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx Institute for Healthcare Improvement. (2017). QI Essentials Toolkit: Failure Modes and Effects Analysis (FMEA) Tool. http://www.ihi.org/resoures/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx Lewin's Change Theory. (2020, July 19). Retrieved December 14, 2020, from https://nursingtheory.org/theories-and-models/lewin-change-theory.php

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