Organizational Systems and Quality Leadership SAT Task 2, Thesis of Management Accounting

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C489 Organizational Systems and Quality Leadership SAT Task 2 College of Health Professions, Western Governors University January 27th, 2021

Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis In 1996, the Joint Commission adopted a sentinel event policy which requires accredited organizations to perform a Root Cause Analysis (RCA) after a sentinel event occurs. An RCA is a systematic approach used to analyze serious adverse events and to identify both active and latent errors. The general purpose of conducting an RCA is to identify the cause of a serious event by looking the sequence of events that lead to the error and prevent future occurrences of the event by establishing a process to prevent the errors that lead up to the sentinel event (PSNet, 2019). This process takes the blame off an individual and looks at system barriers that contributed to the event. A1. RCA Steps An RCA team generally consists of 4-6 team members of individuals at all levels of an organization who have knowledge of the event and the issues and processes involved (Institute for Healthcare Improvement, n.d.). In this scenario, the team would consist of the ED physician, the RN, the LPN, the Respiratory Therapist, the risk manager, and the patient safety representative. The Institute for Healthcare Improvement (IHI) recommends using a 6-step process for conducting an RCA. The first step of an RCA is identifying what happened by describing what happened with accurate and complete details. The next step is for the team to determine what should have happened. The third step is to determine the causes of the event. The IHI recommends asking “why” questions in order to get to the underlying or “root” causes. Step 4 involves the development of causal statements. A causal statement links the cause to its effects and how they relate to the event. It is composed of three parts: the cause, the effect and the event. Step 5 is for the team to collaborate and generate a list of recommended actions that

O2 saturation alarm being noticed by the LPN but not communicated to the RN or physician, and the ED was busy and understaffed. In ideal conditions, the medication would have been administered appropriately, the patient would have had adequate vital sign monitoring and supplemental oxygen in place, there would have been clear communication about the patient status and vital sign alarms, and additional ED staff would have been called in. The first hydromorphone dose should have been administered and the patient monitored for effect for at least 10 minutes. For patient vital sign monitoring, the O2 saturation, BP, ECG and respiratory rate should have been continually monitored and supplemental oxygen administered. As stated by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia (2018), “The use of supplemental oxygen versus no supplemental oxygen is associated with reduced frequency of hypoxemia during procedures with moderate/procedural sedation.” Although it is not listed as part of the hospitals sedation protocol, the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia (2018) recommends that a clinician (other than the one performing the procedure) who is trained in the recognition of apnea and airway obstruction is dedicated to monitoring the patient throughout the procedure. In my experience as a critical care RN, the nurse-to-patient ratio for a patient receiving procedural sedation is 1:1 and the RN is at the patient bedside continuously monitoring the patient until they have met the discharge criteria. Additionally, the newest sedation guidelines require monitoring of the patients’ ventilation via continuous capnography (Kost, 2019). End-tidal Co2 measurement paired with continuous oxygen saturation monitoring and respiratory rate would have been strong objective measurements showing hypoventilation and worsening hypoxia. In addition to the proper

respiratory monitoring that should have occurred, the patient should have also been placed on ECG monitoring prior to the start of sedation. This would have established a baseline heart rate and rhythm and would have most likely shown subtle changes indicating patient decline. Additional ED staff should have been called to allow the RN to remain at the bedside. Last, for the patient vital sign alarms, the LPN should have notified the RN of the alarms so they could intervene by stimulating the patient and applying supplemental oxygen, open the patient’s airway, address the low BP and consider reversal agents prior to the patient coding. To determine the factors and causes that contributed to the event, it is helpful to ask “why.” Why did the nurse administer the doses of hydromorphone so close together, why was the sedation protocol not followed, why wasn’t supplemental oxygen administered, why was there a communication breakdown, why were the alarms ignored, and why did the patient code? There are root causes that apply to multiple contributing factors. The contributing factors are the medication not being administered properly, inadequate vital sign monitoring and lack of supplemental oxygen, no communication about the patient status and vital sign alarms, and inadequate ED staff. The hydromorphone was not administered appropriately because the physician and RN were busy managing the competing priorities of multiple high-acuity patients, and the physician instructed the RN to administer a second dose after only 5 minutes. The RN was distracted and trying to achieve adequate patient sedation so the procedure could be done. The monitoring piece of the sedation protocol was not followed due to respiratory therapy not being called to the bedside and the RN being distracted with juggling multiple tasks caring for multiple patients in a busy ED. Also, the patient was stable throughout the procedure and did not decline until approximately 20 minutes later. If the patient started to decline during the procedure it would

information about peak effect. A sedation checklist should be instituted so clinicians are not expected follow the sedation protocol based on memory alone. A checklist would help assure all clinicians are following the critical pieces of the sedation protocol and work as a cognitive aid to prompt important aspects of the protocol during times of stress and distraction. Last, the ED staffing plan should be reviewed and updated to include specific triggers for when to call in extra ED staff. B. Improvement Plan In order to create a process improvement plan, I would create a team that includes key players such as the ED physician, RN and LPN that were involved in this event. I would also include the risk manager, the safety officer, a respiratory therapist and the ED manager. I would review the patients medical record and relevant documentation, then interview each clinician that was involved in the event in order to understand their perception of what occurred, ask what went right and what went wrong, and what barriers exist. I would then schedule a meeting with the team to review the collected information and determine the root causes of the event. Once the root causes are determined, the team could then create a causal statement that would help guide suggestions in order to form a list of recommended actions that would help prevent a similar event from occurring. The next step would be to create a summary of the recommended actions and educate the ED staff on the findings of the RCA and recommendations of the improvement plan. My proposed recommended actions for improvement are listed above. B1. Change Theory Lewin’s change theory, developed in the 1940’s, describes a three-stage process of change. The three stages are unfreeze, change and refreeze. Unfreezing is acknowledging that a problem exists and recognizing that change is required for the solution. The change stage is

when the change is implemented. It is important that the leaders of this change communicate frequently to describe the benefits and explain how the change will solve the problem. Refreezing is when the change becomes internalized and incorporated into everyday workflow. The success of change is celebrated, and change is sustained (MindTools, n.d.). The first stage of change, unfreeze, consists of acknowledging that change is necessary, and work is done to break down the existing culture related to the change. This must be done before the new culture, or way of operating can be created. For this stage to be successful, people must understand why the change is justified. For the scenario with Mr. B, there are obvious issues that contributed to this event that warrant change. The team can use storytelling about the sentinel event to help explain the justification for the change. The RCA is helpful in looking at the way things were done and what needs to change in order to prevent this situation from reoccurring. The proposed changes include updating the sedation policy, creating a checklist, updating the staffing plan and providing education. Once it is decided how these improvements will be implemented the second stage can occur. During change, the second stage, the changes are implemented. In this scenario, it is utilizing the updated policy and staffing plan, providing education and implementing the checklist. People start to see the positive effects of change and embrace the benefits of it. Some will still be resistant to change, others may not ever embrace it, but over time the majority will adopt the plan, understand the reasoning for the changes, and embrace the new way. During this stage barriers are recognized, and revisions are made if needed. Last is the refreezing stage. This is when the culture becomes the norm. People have adapted and the change becomes part of the organizational structure. In this scenario, the staff has knowledge of the sedation policy and utilizes the checklist for every sedation. The staffing

C2. FMEA Table See separate attachment. D. Intervention Testing In order to test the recommended interventions, I would first have the team “verbally simulate” the changes with some different scenarios prior to implementing in the ED. It is possible that the ideas for improvement are great in theory but flawed or even more unsafe when applied to a scenario. Talking through each recommended action in a mock scenario can assist with finding flaws in the proposed interventions. The team would then develop a goal for improvement such as decreasing the RPN for a failure mode by 50% over 6 months. Once the interventions are implemented into practice, their effectiveness would be tested by auditing the medical record of patients that receive procedural sedation. The patient’s chart would be audited to gather data on how often the checklist is being utilized, what patient vital sign monitoring is done and documentation of abnormal vital signs. This would give information on if the procedural sedation protocol is being followed. Data on any unexpected events or patient codes that occur during or after procedural sedation would also be collected which would show if incorporating best practice is improving the quality of care. This data would be shared with the staff on a quality board posted in a visual place within the department so the staff could see the progress. I would also speak to the ED staff and ask for feedback regarding the implemented changes to assess for any concerns or issues. Last, reports would be pulled on daily patient census and nurse staffing. If there are unexpected events or patient codes during procedural sedation, they are correlated with staffing levels at the time. If the chart audit data is showing that the quality of patient care is not improving, the team would need to reconvene and revise the recommended actions. Communication would go

out to the staff regarding the data findings and revision, the adjusted interventions would be implemented and tested. E. Demonstrate Leadership A professional nurse can demonstrate leadership in promoting quality care and improving patient outcomes by assuring the RN’s on a unit are not only following hospital policy and procedure, but also remaining current with the newest research and current evidence-based practices. I am a nurse manager of an ICU and I regularly read the monthly edition of a critical care RN journal. I discuss many of these interesting articles with my peers and share my knowledge. If I find that my unit has a practice that may put patients at risk or there is an opportunity for improved patient safety, I collaborate with the appropriate key players to update and revise the workflow and incorporate best practice which improves quality of care and patient outcomes. A professional nurse can influence quality improvement activities by being involved within the unit and the culture of patient care, as well as joining and being engaged in hospital committees such as shared governance or unit-based council. E1. Involving Professional Nurse in RCA and FMEA Processes RN’s have unique insight to patient care as they have much more patient contact than other disciplines such as physical therapy or respiratory therapy. When an event occurs or improvement of patient care or workflow is needed, RN’s are an excellent resource. Because they spend so much time with patients, RN’s can provide useful details and help to identify the root causes of event or the failure modes in an FMEA.

Sentinel Event Policy and Procedures. The Joint Commission, (n.d.). https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel- event-policy-and-procedures/. Root Cause Analysis. PSNet. (2019, September). https://psnet.ahrq.gov/primer/root-cause- analysis.