Organizational Systems and Quality Leadership Sample
Root Cause Analysis (RCA) is a critical tool in healthcare organizations because of its role in identifying and analyzing serious adverse health events. RCA is used by healthcare organizations as a tool for analyzing errors and taking corrective measures to contain them before further damage is done. A key factor in RCA is the identification of problems in the healthcare that increase the chances of errors while also minimizing mistakes done by individuals. RCA relies on systems approach technology to identify all types of errors-both active and latent errors (Cherry, & Jacob, 2019). Latent errors are those that are hidden but cause damage to healthcare while active errors are those that occur at the point where humans and complex systems meet. RCA follows a strict specified protocol that often begins with collecting data about an adverse health condition and proceeding to reconstruct the problem with a view of finding effective solutions to contain it. Root Cause Analysis plays an integral role in preventing future injuries and harm by eliminating errors.
Part A1: The Purpose of Conducting a Root-Cause Analysis (RCA)
The objective of carrying out RCA is to analyze serious adverse health events to stop them from causing further harm. The idea behind RCA is to identify the root cause of a problem and construct an effective approach to curbing them at the earliest opportunity. RCA operates on the idea that problems are not only solved when they arise but also finding a way to prevent such problems from reoccurring in the future. Preventing an event from reoccurring saves healthcare organizations resources, time, and money.
6 Steps Used in Conducting Root Cause Analysis
- Problem definition
This is the first step in conducting RCA. In this step, an organization must ensure that the problem faced by customers/patients is aligned with their needs. For example, in the case of Mr. B from the case scenario, Dr. T did not carry out adequate problem identification on Mr. B. For example, Dr. T writes the order for Nurse J to administer diazepam 5 mg IVP to Mr. B. The medication diazepam is administered IVP at 4:05 p.m. After five minutes, the diazepam appears not to affect Mr. B, and Dr. T instructs Nurse J to administer hydromorphone 2 mg IVP. The medication hydromorphone is administered IVP at 4:15 p.m. After five minutes, Dr. T is still not satisfied with the level of sedation Mr. B has achieved and instructs Nurse J to administer another 2 mg of hydromorphone IVP and an additional 5 mg of diazepam IVP.
The physician’s goal is for the patient to achieve skeletal muscle relaxation from the diazepam, which will aid in the manual manipulation, relocation, and alignment of Mr. B’s hip. The hydromorphone IVP was administered to achieve pain control and sedation. It was only after a review of Mr. Bs’ medical history does Dr. T realize that Mr. B’s weight and his regular use of oxycodone make it difficult to sedate him. Another potential problem was that the nurse and doctor attending to Mr. B failed to monitor his respirations and ECG.
- Data Collection and Determining what should have Happened
After a problem has been identified and properly defined, the team must gather sufficient data and information that support the problem identified. For example, from the case scenario given, the team must gather as much information about each patient as possible. Some of the critical data to focus on include; previous history of the problem, recurring health problems, potential side effects from certain medications among others. Most importantly, the team must evaluate what was done differently and what should have happened in an ideal situation.
- Determining the Causes
At this point, the team must ask themselves the causes of the identified problem or the factors that led or contributed to the event. Here, the team looks at both the contributory factors-the indirect causes, and the direct causes of a problem. The Institute for Health Improvement-IHI supports a fishbone diagram is one of the critical tools in identifying the factors that cause a problem.
- Developing Causal Statements
A causal statement links the identified problem to its effects. Here, the team must find out all the effects that arise from the identified problem and then link it back to the main event. For example, in the case of Mr. B, his original problem was severe pain in his leg and hip resulting from falling. However, a failure on Dr. Ts’part to overlook Mr. Bs’weight and other health problems record resulted in the administration of several different sedation drugs. The patient was also not put on supplemental oxygen and neither was his respiration and ECG monitored. These are problems that were created by the attending physician and nurse that led to the deterioration of Mr. B’s health and eventual death.
- Preventing a Reoccurrence of the Event
Having identified an event and its effects, the next step is to recommend actions to take to avert a reoccurrence of the problem in the future. For example, one of the recommendations that the team may find useful based on the case scenarios is identifying strategies that force users to avoid making errors. Another recommendation that the team may find useful in preventing future recurrence of similar problems is eliminating redundancy by performing double checks and having backup systems.
- Writing a Summary/ Monitoring and Sustaining
Here, an organization must ensure that the recommended changes aimed at preventing a reoccurrence of the identified problem are strictly implemented. The new changes must be continuously monitored and sustained to ensure operational excellence.
Part A2: Causative and Contributing Factors in RCA
There is a clear difference between a root cause and a contributing factor. The root cause is the underlying condition that creates a harmful event to happen/occur while a causal factor is an unintended contributor to an event. A root cause of an event influences the process. If the event has no relationship with a causal process, it is not possible to have a causal factor (Kellogg et al., 2017). It is critical to remember that a causal factor is not caused by a single event but rather by a series of events that eventually influence the outcome of the initial main problem. This is to say that the main event/root cause can happen again even without the causal factor.
Root causes are the underlying issues that lead to the happening of a harmful event while causal factors are factors that contribute to the worsening of the main issue/problem. For example, from the case scenario of Mr. B., his root cause of hospitalization was hip and leg pain caused by falling after tripping. However, an attempt to have Mr. B sedated went bad after Dr. T ordered the attending nurse to administer several different sedatives on Mr. B without a thorough look at his medical history such as weight. Secondly, Mr. B was not put on supplemental oxygen, neither was his ECG and reparations monitored. These causal events led to the deterioration of Mr. Bs’ health and eventual death.
Part B: The Improvement Plan/ Lewin’s Change Theory
Kurt Lewin developed the Change Theory of Nursing using a three-stage model to induce change in an organization. The fundamental tenet of Lewin’s model of change theory is that for effective changes to occur in an organization, any prior learning must be entirely rejected and completely replaced. He came up with the model of change known as unfreezing-change-refreeze. Lewin defined behavior as the balancing of forces pulling in opposite directions. In his theory of change, Lewin asserted that there are driving forces in human behavior that push in a certain direction causing change to occur.
In the unfreezing stage, Lewin asserts that organizations must find a way or process that makes it possible for people to leave the old patterns of behavior. For example, an organization can create a compelling message to its human resource showing them why the old way of doing things cannot and must continue. This can be done by challenging the current behavior, values, and attitudes.
In the change stage, the uncertainty created in the unfreezing stage makes people find ways of resolving it by finding new ways of doing things. While this transition does not occur overnight, Lewin asserts that this is the stage where an organization can inject the values, beliefs, and behaviors it wants to have. The last stage of Lewin’s change model is refreezing. At this stage, people have accepted and embraced the new values, beliefs, and behavior and now it is time for an organization to make sure that the changes are operational at all times.
In the case scenario provided, one of the problems with the staff is carelessness which results in petty but costly medical errors. For example, in the case of Mr. B., a simple check of his medical record would have revealed to the attending doctor the appropriate sedative to use on him based on his weight. However, the doctor ignored to check the patient’s weight and instead administered several different sedatives after the initial sedatives failed to work. Secondly, after attending to Mr., the nurse failed to monitor the patient’s ECG and respiration. This careless behavior caused the patient his life. Lewin’s change model can be used to help the nurses and other caregivers at this hospital change their behavior, attitude, and beliefs to diligently carry out their duties.
Part C: Purpose of Failure Mode and Effects Analysis (FMEA)
Failure Modes and Effects Analysis-FMEA is a step-by-step method of identifying failures in a process or system. The term failure modes refer to ways in which something can fail due to errors or defects in the system. Effects analysis, as defined by Black (2019), is the act of studying the consequences occasioned by the said failures. Thus, the purpose of FMEA is to take action at the earliest opportunity to eliminate potential or actual failures putting the focus on ones with the highest priority.
In assessing failure modes, priority is given to situations according to the seriousness of their consequences. Besides, an organization must determine the frequency of the failures and how easily they can be detected. For example, from the case study given, one of the recurring failures in the case scenario is medical errors. The medical errors shown in the case study are not due to a lack of knowledge or proper training on the part of the doctors and nurses but due to petty negligence and carelessness. An FMEA would reveal the extent of the problem in this facility and the consequences of such actions on the patients and the organization.
Part D: Testing the Interventions
The intervention chosen to solve the identified problem is creating a new organizational culture aimed at instilling new behavior, attitudes, and beliefs. Some of the steps critical to the implementation of the new organizational culture include; aligning the culture with the aims and objectives to be achieved, defining the new sets of values, behavior, and beliefs, creating and defining the non-negotiables, and demanding accountability.
Having set the parameters necessary for the implementation of the invention, it is critical to test the intervention. One way through which the intervention can be tested is by comparing current behavior, beliefs, and attitudes against previous ones. If the scores are low on these parameters, it means no visible changes are happening. If the score indicates upward changes, it means that there is an improvement.
Another critical way of testing the intervention chosen is by getting feedback from the customers/patients. The positive response from customers is an indication of an improvement in the changes while a negative response from customers means that things have not changed. Customers are an essential tool in evaluating change in an organization. Surveying customer satisfaction can show the direction the organization is headed. Similarly, a customer survey can reveal to an organization if new changes are working or not.
Part E: Demonstrating Leadership by Nurses
1.Promotion of Quality Care
Nurses can demonstrate leadership in promoting quality care through qualities such as clear communication, collaboration with others, and promoting a conducive environment for work engagement. In the promotion of quality care, nurses must have the right skills and education, attitude, behavior, and beliefs. To begin, the promotion of quality care begins with the knowledge and understanding of the four principles of nursing-autonomy, justice, nonmaleficence, and beneficence. An understanding of these principles helps nurses to form and create effective personal and nursing theories that promote quality care.
- Patient Outcomes
Nurses can demonstrate leadership in improving patient outcomes by engaging in activities that boost patient safety and care. Nurses can positively impact patient outcomes by promoting and supporting positive care for patients. This factor means that nurses must act and behave in ways that enhance patient safety and satisfaction at all times. For example, not bringing harm to patients is one way of promoting patient satisfaction. For instance, from the case scenario provided, Dr.T. could have evaded bringing further harm to Mr. B. if he acted right by consulting the patient’s health record.
- 3. Influencing Quality Improvement
Nurses must improve the quality of care they provide to patients. Nurses leaders can influence the organizational culture to create a positive work environment where nurses ‘behavior, attitudes, and beliefs are oriented towards the provision of quality care to patients. Secondly, nurses must think about how their actions, attitudes, personal worldview, and behavior impact the quality of services they provide to customers (Sluggett et al., 2019). Nurses must put aside their personal biases and prejudice related to race, religion, and personal worldview when dealing with patients Nurses must have good nursing philosophies to enhance the quality of care they provide.
A good nursing philosophy is based on critical values and beliefs such as compassion, integrity, human dignity, and altruism. These factors enable nurses to get a clear and accurate patient diagnosis treatment as well as identifying areas of priority. Key responsibilities that define the conceptual framework of nursing practice are based on improved patient outcomes. A nurse’s core duties include promoting patient safety, managing the patient environment, providing individualized care, creating a positive interpersonal relationship with patients, and using evidence-based practices in inpatient intervention. As a nurse, some of the values and beliefs that are critical are a combination of a set of principles that include altruism, human dignity, caring, and integrity.
Part E 1: The Involvement of the Professional Nurse in The RCA and FMEA Processes Demonstrates Leadership Qualities
As part of the FMEA team, nurses can demonstrate leadership by identifying causes of problems, risks, and the severity of errors. According to Pena and Melleiro (2017), RCA looks back at what has already happened and how to prevent the same from reoccurring in the future. FMEA looks ahead to what could happen and devising solutions to stop it from happening. Based on this analogy, in RCA, nurses can help to identify the causes of problems and contribute to finding solutions so that such problems are reduced or avoided in the future. Nurses spend more time with patients than any other caregiver, thus, their input on preventing potential problems is critical as they understand the ‘ground’ better than other healthcare workers when it comes to patient matters. Regarding FMEA, nurses can demonstrate leadership by actively contributing to finding solutions to stop potential or actual harm from happening in the future.
Nurses can competently demonstrate leadership through their skills, education, and training. The most critical skills regarding skills training and education are conceptual skills, human skills, and technical skills. Using these three competencies, nurses can adequately demonstrate leadership through the promotion of quality care. These three factors have a big impact on the quality of care given to patients as well as patient outcomes. Besides these skills and competencies, nurses must have effective communication skills to enhance quality care. Effective communication skills are essential for communication with both colleagues and patients as well as external customers. Effective communication skills promote an environment of care and positive organizational culture.
Root Cause Analysis is a critical and essential tool in healthcare because it helps healthcare organizations tackle potential and actual health problems. An RCA is used by healthcare facilities to analyze the nature of problems and take corrective measures before they explode into bigger problems. Conversely, an FMEA- Failure Mode and Effects Analysis is a tool used by organizations to analyze failures in their systems or processes. The difference between RCA and FMEA is that the former looks at what has already happened and how it can be remedied. It also looks at how the same can be stopped from happening in the future. The latter-FMEA looks at the future by anticipating potential problems and devising ways to avoid them before they happen. FMEA also looks for solutions to mitigate the impact of the anticipated problem so that should they occur, solutions are ready.
- Black, J. M. (2019). Root cause analysis for hospital-acquired pressure injury. Journal of Wound Ostomy & Continence Nursing, 46(4), 298-304. https://doi.org/10.1097/won.0000000000000546
- Cherry, B., & Jacob, S. (2019). Contemporary nursing: Issues, trends, and management (8th ed.). St. Louis: Mosby Elsevier.
- Kellogg, K. M., Hettinger, Z., Shah, M., Wears, R. L., Sellers, C. R., Squires, M., & Fairbanks, R. J. (2017). Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?. BMJ Quality & Safety, 26(5), 381-387. https://doi.org/10.1136/bmjqs-2016-005991
- Pena, M. M., & Melleiro, M. M. (2017). The root cause analysis method for the investigation of adverse events. Journal of Nursing – UFPE Online [Internet], 11, 5297-304. https://doi.org/10.5205/1981-8963-v11i12a25092p5297-5304-2017
- Sluggett, J. K., Lalic, S., Hosking, S. M., Ilomӓki, J., Shortt, T., McLoughlin, J., Yu, S., Copper, T., Robson, L., Van Dyk, E., Visvanathan, R. & Bell, J. S. (2019). Root cause analysis of fall-related hospitalisations among residents of aged care services. Aging Clinical And Experimental Research, 32, 1947-1957. https://doi.org/10.1007/s40520-019-01407-z