Essay Sample on General Purpose of Conducting Root Cause Analysis

Following a decree by the Joint Commission on Accreditation of Healthcare Organizations, the conduction of RCAs in all sentinel events has become mandatory. The argument for such a directive is based on the fact that such analyses can be of enormous value. The RCA model captures the broader perspective and details of the event by facilitating system evaluations, evaluating for the need of corrective action, tracking and trending. In regard to the trending concept, the manager will be able to be in a position to determine how frequently a particular error occurs using certain parameters such as an instrument error or which unit of the hospital is involved. Such information provides insights into a particular problem and especially in health care related disciplines as it provides an evidence based approach even in near-miss scenarios. Equally important is the fact that RCA ought to be performed as soon as a variance and error occurs others there exists the prospects of missing important details (Bowie, Skinner & de Wet, 2013). Additionally, all the personnel that are involved in the error must be included in the analysis as a stratagem of avoiding speculation which will dilute the facts of the case. The nurse manager has the responsibility of informing the staff of the essence of RCA to avoid instances of apprehension and hostility. In essence, RCAs are to be perceived as a means of rectifying an error rather than apportioning blame to the parties involved.

Steps used to Conduct RCA

Conventionally, an RCA team is comprised of a small team of individuals of between four to six individuals who are preferably drawn from different professions. Moreover, the team include persons at different levels of the organisation who are conversant with the fundamental processes and issues arising from an incident. Equally important is the fact that administrative and clinical leaders are instrumental in offering support to the RCA model. The most fundamental step involves identifying what happened where team members attempt to obtain an accurate and explicit decision of what transpired. The clarification and organisation of information about a particular event may be achieved through the use of simple instruments such as a flow chart diagram depicting a picture of what occurred and in the order in which it occurred. The second step mainly integrates information that describes what ought to have happened in ideal conditions and an alternative flow chart may be created and compared with the one that was developed in Step 1. The third step involves the determination of the causative agents which contributed to the even. The team looks at the most apparent causes including contributory factors which are indirect in nature such as the conditions, circumstances and conditions that may have augmented the occurrence of the sentinel event (Nicolini, Waring & Mengis, 2011).

Contributing factors do not necessarily amount to root causes and as such experts recommend that RCA teams ask why five times in order to identify the underlying causes. The most commonly used tool for grouping and identifying factors is the fishbone diagram which presents a graphic tool which is used to display and explore the possible causes of a certain effect. The fourth step involves the development of causal statements which link the causes identified in step 3 back to the main event that spurred the advent of the RCA. Creation of causal statements is instrumental in explaining how the set of facts about a current scenario contributes to the negative outcomes for the staff and patient (Shaqdan et al., 2014). The next step involves generating a list of recommended actions which would aid in preventing the recurrence of the event. In essence, the recommended actions are alterations that the RCA team presumes will assist in pre-empting an error under review from occurring in future. The final step is concerned with summarising and sharing the findings at the conclusion of the RCA process. This step is seen as being an opportunity to engage stakeholders who would help in spearheading the next steps in improvement.

Application of RCA to the Scenario

In the case of Mr. B the conduction of an RCA reveals system errors embedded within the health care organisation in which the patient was administered. Despite the fact that there was backup staff on the day the event occurred, the organisations system is seemingly faulty in the sense that no clearly defined procedures exist for covering shifts or supplementing the understaffed departments. As a result, the ED that received Mr. B on the day of the event was comprised of two primary care, an RN and LPN who were already attending to two other patients. Following the successful sedation and subsequent reduction of Mr. B hip, the patient is to be monitored in accordance with the conscious sedation policy of the health care facility until the patient attains the specific criteria for discharge. Nonetheless, Nurse J appears to neglect the fundamental guidelines set by the hospital where the patient is required to be placed under continuous B/P, ECG and pulse oximeter until discharge. The patient was not placed in supplemental oxygen while his respirations and ECG were not monitored and this ultimately culminated in brain death of Mr. B. Additionally, the number of patients who required immediate attention that necessitated an RNs proficiencies were more than the available staff and as such Nurse J was overwhelmed and perhaps opted for more convenient approaches in the face of demanding situations.

Process Improvement Plan

Inappropriate nurse-patient ratio results in adverse health outcomes for patients and this occurrence may be attributed to concerns raised about the safety of patients and the quality of healthcare that is to be delivered. As a result, the rural hospital in which Mr. B was arrested needs to strike a balance between the nurse to patient ratio ensures that the workplace environment conditions are optimised. Additionally, the ultimate function of ensuring a proper nurse to patient ratio is embedded in the fundamental purpose of instituting approaches that are directed towards patient safety (Hutchinson & Jackson, 2011). As such the typical potential actions would include establishing the practice of evidence-based leadership and management; adequate staffing; provision of clinical decision-making support and lifelong learning structures for nursing staff; implementing mechanisms that facilitate interdisciplinary collaboration and a feedback system that alternates with training sessions geared towards patient safety.

Lewins Change Theory

Lewins management model has been adopted by most health organizations as the ideal measure. The model comprises of a three-pronged approach dubbed the unfreeze-change-and refreeze steps (Manchester et al., 2014). The first step denotes preparation of the organization to accept that change is inevitable where the present status quo is broken down before rebuilding a unique mode of operation. A compelling message is thus developed to justify why the current methodologies are not working and why there is need to introduce new measures. For instance, the prevalence of miscommunication between residents and the staff may necessitate the introduction of awareness posters which serve as a reminder of how to deal with patients (Axelsson et al., 2014). After the unfreezing stage, people began dealing with the uncertainty and begin doing things differently. Gradually, team members gain belief in the new system and support the new regime that has been put in place. Moreover, staff begins adopting a new direction proactively, and when things take shape, the organization is ready to refreeze. Refreezing is characterized by accurate job descriptions and organizational charts which help people in internalizing the alterations effected. In essence, this leads to the utilization of the changes at all times offering a new sense of stability where employees feel comfortable with the new techniques that are now part of the organizational culture.

General Purpose of Failure Mode and Effects Analysis (FMEA)

The FMEA denotes a structured way of identifying and addressing prospective problems or failures and the resulting effects on the system before an adverse event occurs. Additionally, FMEA is concerned with identifying and eliminating process failures for purposes of preventing an undesirable event. FMEA may be utilised in evaluating both new and existing processes where the former involves identifying potential bottlenecks prior to implementation while the latter is primarily concerned with the comprehending how the proposed changes will affect the system.

Steps of FMEA

The first step involves the selection of a process that is known to be problematic such as the identification of processes that have not met the criteria to achieve the desired result. The next step involves the establishment of a leadership structure which provides a project charter to launch the team. Team members are directly involved in the process that is to be analysed while the facilitator is appointed by the leadership. The third steps involves the clear definition of the process steps so that team members become aware of what is being analysed. The next phase integrates a brainstorming session where people who are directly involved in the process describe the problems that are likely to occur (Ashley et al., 2010). The fifth step involves a focus on improvements on the problems that recur often and have a significant impact on the patients and staff. The next phase may be categorised as being pre-emptive in the sense that team member determine how best to change the process to guarantee patient safety. The final step is concerned with the success rate of the preventive measures that have been adopted in order to select evidence and practice-based models to be incorporated into the system.

Testing Interventions from Process Improvement

The establishment of evidence-based leadership and management may be demonstrated through the empowerment of team leaders where they can make independent clinical decisions especially in situations of critical care. In the case of Mr. B, there should have been provisions to enable Nurse J seek assistance from the backup staff even when the nurse manager is not available. Furthermore, the improvement of nursing to patient ratio would ensure patient safety by limiting avoidable errors by sensitising on the need for patient centered care. Equally important is the fact that team leaders should insist on the strict adherence to the professional code conduct that is akin to a particular organisations where the expected outcome would be decrease in preventable deaths at the ED.

How a Nurse Demonstrates Leadership

A nurse demonstrates leadership in quality care by aspiring to comply with the academic requirements as stipulated by health professional bodies. Contemporary research indicates that the attainment of a BSN is directly proportional to the improvement administration of quality care owing to the optimisation of professional proficiencies in an individual. Additionally, a nurse may demonstrate leadership in improving patient outcomes through reporting of incidences of error with the objective of informing the concerned parties to develop counterproductive measures that would mitigate adverse patient outcomes (Curtis, de Vries & Sheerin, 2011). A nurse may also influence quality improvement strategies by undergoing frequent trainings that equip professionals with knowledge and expertise on the current trends and evidence-based measures to be adopted owing to the dynamism of the health care sector.

How Involvement in RCA and FMEA Processes Demonstrates Leadership

The participation of a prof...