Organizational Systems and Quality Leadership Task 22 C489

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1 Organizational Systems and Quality Leadership Task 2 Western Governors University

2 A. Is an organized approached to understand the causes that resulted in a harmful event. Root cause analysis provides a retrospective view of the error that occurred to result in a harmful event focusing on faults in the system rather than blame (IHI, 2019). 1. According to the Institute for Healthcare Improvement (IHI) there are 6 steps most commonly used in implementing a root cause analysis. Step one consists of the RCA team recall what happened by describing the series of events accurately and entirely to organize and clarify all information about the event. Sometimes a flow chart can be created to help organize the information received. In step two the RCA team determines what should have happened by determining what an ideal situation would have looked like. In step two it can also be helpful to create a flow chart based on the information collect under ideal conditions to compare to the flow chart created in step one. In step three, the RCA team pinpoints the cause by asking why five times to get to the root cause of the event. This step helps the team to determine the factors that lead to the event by examining the direct and indirect factors that contributed to the adverse event. In this step it is encouraged to use a fishbone diagram which helps to explore possible causes of certain effects. Step is when the RCA team develops a causal statement. Step four is when the RCA team develops a causal statement. A casual statement is a 3-part statement that explains factual factors that contributed the negative outcome for patients and staff. Step five focusing on the preventing the recurrence of the event. In this event the RCA generates a list of changes that they think will prevent the error under review from happening in the future. There are several recommendations that fall in similar categories that some can define at strong, intermediate and weak actions. So, actions are more effective than other with dealing with the root causes of an error. Step six deals with the

3 RCA team writing a summary report that may contain a flowchart to use to engage the key players in this analysis. To clarify information about the event to help to encourage the next steps in improvement in patient care (IHI, 2019). 2. This scenario consists of a 67-year-old man name Mr. B who was brought into the emergency department by his son after sustaining a ground level fall. Which caused him to have pain to his hip that he stated was 10 out of 10. Mr. B’s vital signs were stable upon arrival. After Nurse J evaluated Mr. B and informed Dr. T of her findings, Dr. T then proceeded to evaluate Mr. B. Dr. T gave orders to Nurse J to administer medication to Mr. B for the purpose of achieving skeletal muscle relaxation to perform left hip reduction on Mr. B while he is under sedation. Nurse J administered 5 mg of diazepam IV push at 4:05 p.m. and hydromorphone 2 mg IV push at 4:15 p.m. per Dr. T order. After 5 minutes Dr. T gave Nurse J an order to administer another dose of hydromorphone 2 mg IV push and diazepam 5mg IV push. Within 20 minutes of administration of the first does of analgesic Mr. B appeared to be sedated to Dr. T’s satisfaction at 4:25 p.m. After the bedside procedure was performed by Dr. T, Mr. B was left in the room to rest while being on continuous pulse ox monitoring and blood pressure monitoring every 5 minutes. Mr. B’s vital signs started to decline Nurse J was alerted of it by the alarms, but no intervention or notification of the physician was taken place. By 4:43 p.m. Mr. B’s B/P 58/30 and O2 saturation is 79% and no pulse could be felt so a stat code had been initiated. Mr. B had to be intubated and eventual had to be transported by flight to a tertiary facility for advanced care, Mr. B later died. This sentinel event was attributed to respiratory arrest secondary to conscious sedation. There were several factors that lead to this event such as: Alarms being dismissed, more time in between

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4 analgesic medication administration, no oxygen supplementation given to Mr. B prior to the initiation of conscience sedation, Mr. B was not on continuous ECG monitoring to inform the nurse of the change in rhythm, influx of new patients into the ER, lack of staff, Dr. T did not review Mr. B’s medication history of opioid use nor was he aware of his weight before giving orders to the nurse to administer the analgesics, Nurse J did not notify Dr. T of Mr. B’s decreasing O2 saturations nor did she administer oxygen to Mr. B. Supplemental oxygen is part of most hospital protocols when a patient is under conscience sedation. Mr. B required conscious sedation specific monitoring in between does’ of IVP analgesics administration to monitor his vital signs, level of consciousness, orientation status, O2 saturation and pupils. All of these were contributing factors that led to the sentinel event, a root cause analysis is needed to prevent an event a reoccurrence of this event. B. The process improvement plan that would likely decrease the reoccurrence of the scenario would be to develop a collaborative task force team. This team can consist of 4 to 6 members from varies departments such as a pharmacist, the manager of ER, clinical educator, manager of the post anesthesia care unit, and 2 lead ER staff nurses. This team would come together first to try to describe what actually occurred as accurately as possible, by doing reviewing chart audits, incident reports made, feedback gathered by staff. Then the team will modify the scenario to imagine if how things would have resulted under idea conditions. The team would then, gather and review data on the event that occurred such as: work environment, characteristics of the patient, relating task factors, individual staff members, organizational management, team factors. The team could use a cause and effect, or a wishbone graph to help organize the data found to be able to

5 determine the contributing causes. The team would then develop a causal statement that connects the cause to its effects and then back to the sentinel event. Then, the team will come up with a list of recommended changes to be implemented to prevent reoccurrence. Changes such as creating a checklist for the nurse to complete if caring for a patient receiving conscience sedation, develop new policies for that unit concerning conscience sedation administration, modify the electronic charting system to add additional charting to be done when caring for these types of patients and staff education. Finally, the team would write a summary of the information gathered and recommended changes. This summary creates an opportunity to engage the primary staff members from the event to provide education and improvement in patient care (IHI, 2019). 1. Kurt Lewin has developed a model for change that consists of three phases unfreeze, changing and refreezing. This model provides a practical way for understanding to process of change and steps to take to create a change. The initial step unfreezing helps to create awareness that change is needed. By examining old behavior patterns, thinking processes, organizational structures provide information to employees to acknowledge change is needed, and to be willing and motivated to accept the change. This could be carried out by the managers holding a mandatory meeting for all of the staff on each unit to informed them of the new policy changes. Now, that employees are motivated to accept change, the second phase of this theory can take place. Changing, can be seen as the transitioning or moving phase because it is marked by implementation of the change. Change is a process that would require an organization to transition into a new state of being. During this stage employees are provided with education material from management on the new policies. The education department can provide educational material on new evidence-based practice for performing skills. The hospital can

6 conduct a skill check off event to educate and assess an employee’s ability to understand and carry out the new change in performing certain skill related to the change in policy. Support from management to aid in this process of learning new behaviors and a new way of providing care to patients is also needed during this phase as well. The final phase referred to as refreezing is the time for the hospital to reinforce, stabilize and solidify the new change that has occurred. This step is in place to ensure that the employees do not go back to the previous ways of providing care prior to a change being made. Once a new policy has been implemented in a hospital it become a permanent standard for the organization to follow in providing care and services to patients (IHI, 2019). C. The Failure Modes and Effects Analysis (FMEA) is a process that works proactively to anticipate ways to prevent potential errors from occurring and helps to initiate a plan of action to prevent them before they occur (IHI,2019). 1. Step one in this process starts off with choosing an issue to evaluate. Preferably a topic that is not a large or complexed issue. Step two, consist of selecting members to join this multidisciplinary team. The team should consist of everyone who is involved at any point in the process. Step three requires the team to list out all the steps in the process. Since the team consist of every person involved in the process each team member is able to provide their own perspective on each point of the process, so that the entire team can come together and agree upon a specific list of steps. Step four consist of the team filling out the table, starting by filling out the numbered column with its particular process then filling out the remaining columns. The remaining columns have specific requirements such as: failure mode (what could go wrong or anything that could go wrong), failure causes (asks why would the failure happen?), failure effects (what would be the

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7 consequences of the failure?), likelihood of occurrence (rates this inquiry from 1-10 with 10 the most likely), likelihood of detection (which is asking what is the chances of the failure will not be detected if it does occur rating this from 1- 10, 10 being not likely to be noticed), severity (could this issue cause severe harm and how likely is it to rating it 1-10, 10 being most likely to cause sever harm), risk profile number (consist of multiplying the 3 scores to get an overall number), actions to reduce occurrence of failure. Step five requires the use of the risk profile number. This number can be as low as 1 and high as 1,000, this number helps the team to evaluate which failure modes has the highest scores and to prioritize the improvement efforts towards those areas. FMEA can be used to reduce harm from failure modes, evaluate the potential impact of hospital/facility changes under consideration or even help to monitor the progress of improvement over time (IHI, 2019). D. The interventions mentioned in part B would be tested by using the four-stage problem solving model called PDSA. PDSA stands for Plan-Do-Study-Act. Step one which is Plan, would consist of addressing the topic of how conscious sedation can be administered and monitored safety under the new policy. The new policy would require the physician and the nurse to both fill out their own separate checklists when ordering conscience sedation. Theses checklist upon completion must be attached to the patient’s paper chart. This checklist for the nurse would consist of specific requirements in conscience sedation administration such as the amount of time to wait in between mediation administration, monitoring of all vital signs every 5 minutes and documenting it, continuous ecg monitoring and supplemental oxygen administration. The checklist for the physician would consist of questions such as: have you reviewed the patient’s past medical history, have you

8 reviewed patients home medications and what is the patient’s weight. Step two which is Do, the physicians and nurses would have an educational meeting about the new hospital policy and then the checklist would be placed at an accessible spot in the ER for the staff to utilize. The third step in this process is Study, this will be a chance for the team that has initiated this new hospital policy to evaluate the effectiveness of the checklist with patient care being delivered and patient outcomes. The last step is Act, which is the step that sheds light on any needs for improvement in the new policy and then implements additional change (IHI, 2019). E. professional nurse demonstrates leadership by promoting quality care when monitoring for signs and symptoms of early recognition of complications, adverse events and errors. This allows the nurse to alert about any change in the patient’s condition to intervene in a significant way. A professional nurse can also improve patient outcomes by contacting the physician for timely intervention, response and rescue of patients in a situation that is trending down or is critical. This action gives the nurse to make life saving decision by contacting the appreciate physician in a timely manner. A professional nurse also influences quality improvement activities by promoting effective workforce planning by encouraging safe nurse to patient ratios and by actively participating in policy making (Werner, 2017). 1. Being involved in an RCA or a FMEA gives the professional nurse knowledge and understanding about an adverse event or a potential adverse event. It also provides the nurse with the opportunity to be a part of the interdisciplinary team to analyze but to also create a plan of action of improvement for the issues. It requires leadership skills to be able to work with a select group of people to put ideas together to create a plan of action that will affect the way that hospital or facility provides care to the community that it serves. The

9 professional nurse may also have to be part of the implementation process to educate other nurses on what the new policy is about and how to implement it. It takes a leadership qualities to be able to teach a group of professional nurses on how to perform a task differently (Schmidt, 2013).

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10 Reference Werner, Kathleen M. (2017). Quality Improvement and Patient Safety. Retrieved from https://wgu.vitalsource.com/#/books/9780323390224/cfi/6/72!/4/2/2@0:0 Institute for Healthcare Improvement. (2019). The Change Theory. Retrieved from http://www.ihi.org Institute for Healthcare Improvement. (2019). Failure Modes and Effects Analysis (FMEA) Tool. Retrieved from http://www.ihi.org Institute for Healthcare Improvement. (2019). Root Cause and Systems Analysis. Retrieved from http://www.ihi.org Schmidt, Brooke. (2013). The Roles of Nurse Leaders in Quality and Patient Safety. Retrieved from https://www.psqh.com/analysis/the-role-of-nurse-leaders-in-quality-and-patient safety/

Organizational Systems and Quality Leadership Task 22 C489

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