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Root Cause Analysis and Improvement Plan in Organizational Systems and Quality Leadership, Thesis of Business Accounting

University of Phoenix (UOPX)Business Accounting

Root Cause Analysis (RCA) and Improvement Plan in Organizational Systems and Quality Leadership. RCA is used to evaluate the sequences of events that occurred to allow an adverse event to occur. the six steps involved in a typical evaluation of RCA and how to develop a causal statement. It also discusses the Change Theory by Lewin and how it can be applied to develop an improvement plan. The document emphasizes the importance of involving professional nurses in RCA and FMEA processes.

Typology: Thesis

2023/2024

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C489
Organizational Systems and Quality Leadership
SAT Task 2
Western Governors University
Organizational Systems and Quality Leadership SAT Task 2
A. Root Cause Analysis
A Root Cause Analysis is used to evaluate the sequences of events that occurred to allow
an adverse event to occur. Root Cause Analysis is retrospective, meaning after the event. It
allows staff to evaluate the cause and events that led up to the event in systematic order and be
able to identify system flaws that can be corrected to prevent this from happening again.
A1. RCA Steps
There are six steps that are involved in a typical evaluation of a Root Cause Analysis.
They are as follows identify what happened, determine what should have happened, determine
Causes, develop causal statements, generate a list of recommended actions to prevent the
recurrence of the event, and write a summary and share it.
A2. Causative and Contributing Factors
In this scenario a root cause analysis would be presented as step 1 what happened? Mr. B
was given several doses of sedation because of his tolerance to opioids. Immediately after
medication administration Mr. B was left alone with his son. Mr. B was placed on the monitor to
have continuous monitoring. Because the staff was busy with other patients several alarms were
ignored. As a result, Mr. B’s blood pressure and oxygenation was significantly decreased which
led to Mr. B needing to be intubated and have CPR. Mr. B ended up dying.
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Organizational Systems and Quality Leadership SAT Task 2 Western Governors University Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis A Root Cause Analysis is used to evaluate the sequences of events that occurred to allow an adverse event to occur. Root Cause Analysis is retrospective, meaning after the event. It allows staff to evaluate the cause and events that led up to the event in systematic order and be able to identify system flaws that can be corrected to prevent this from happening again. A1. RCA Steps There are six steps that are involved in a typical evaluation of a Root Cause Analysis. They are as follows identify what happened, determine what should have happened, determine Causes, develop causal statements, generate a list of recommended actions to prevent the recurrence of the event, and write a summary and share it. A2. Causative and Contributing Factors In this scenario a root cause analysis would be presented as step 1 what happened? Mr. B was given several doses of sedation because of his tolerance to opioids. Immediately after medication administration Mr. B was left alone with his son. Mr. B was placed on the monitor to have continuous monitoring. Because the staff was busy with other patients several alarms were ignored. As a result, Mr. B’s blood pressure and oxygenation was significantly decreased which led to Mr. B needing to be intubated and have CPR. Mr. B ended up dying.

Step 2: What should of happened? When Mr. B received moderate sedation, he should have been attached to a cardiac monitor and monitored closely by a trained nurse until he was awake and alert per hospital policy. More staff should have been called in because Mr. B was now a 1 on 1 care. Step 3: Determine Causes. The cause of this adverse event was improper monitoring during moderate sedation and lack of adequate staffing for the procedure. Step 4: Develop Casual Statement. The emergency room became busy and understaffed, which led to Mr. B not being monitoring correctly which caused Mr. B’s diminishing vital signs to not be noticed which led to his demise. Step 5: List of Recommendations. Some recommendations would be to review hospital protocol for moderate sedation, not only the procedure but also the staffing needs required to perform. Initiate a program for yearly evaluation and refresher education. Step 6: Summary. Provide a written root cause and analysis and share with other staff in the emergency room to prevent the possibility of a reoccurrence. B. Improvement Plan A possible process improvement plan would be to develop a check off requirements to perform moderate sedation. Including placing patient on the monitor, frequent vital signs, and staffing for procedure. B1. Change Theory The Change Theory by Lewin (1951) involves three stages. The three stages are as follows unfreezing, moving, and refreezing. In our case, the unfreezing stage would be where we gathered information, accurately assess the problem, decide whether change is necessary, and

These are the ones the team should work on first. This is done proactively to avoid an adverse event and prevent from happening. C2. FMEA Table NOTE: see attached D. Intervention Testing As a member of this task force, I would evaluate the success of the moderate sedation checklist. I would evaluate whether any near misses or sentinel events have occurred. Then the information would need to be evaluated with the patient’s chart. I would also make sure the checklist is being used as its highest capabilities for greatest results. I would do an audit of every checklist and make sure we were hitting a target of at least 95%. I believe that using a checklist will improve patient outcomes and satisfaction. By doing this audit I will be able to prove the checklists success and proven positive outcomes. E. Demonstrate Leadership Leadership is defined as the act of guiding or influencing people to achieve desired outcomes, occurs any time a person attempts to influence the beliefs, opinions, or behaviors of an individual or group (Hersery and Blanchard, 1988). A professional nurse can demonstrate leadership by encouraging quality care by staying educated on new evidence-based practice information, and treatments in their area of expertise. Leadership also involves being able to delegate tasks to the appropriate staff member based upon their competencies. Also following up with her team and patients to evaluate satisfaction with the care they are giving and receiving. An important thing to remember is if staff are not satisfied or fulfilled in the care they give; the

patients will feel it and know it. Leadership should also advocate for safe staffing ratios. This is not only determined by number but also acuity. It is important for leadership to get report on the patients on the floor to determine the acuity before making assignments. This will assist in staff satisfaction and fulfillment. Lastly, if the professional nurse encourages quality improvement activities to the other staff members, through evidenced based data of improved outcomes, this will improve overall quality. Nurse go into this professional to take care of others and give them the best quality they can. If leadership feeds off of this reasoning of entering the profession, changes will occur in the quality. E1. Involving Professional Nurse in RCA and FMEA Processes Involving the nurse in the RCA and FMEA processes allows her to demonstrate leadership by using her voice and knowledge to improve her professional career. Her coworkers will see her involvement (if done for the right reason) and want to be involved to improve their work area. A nurse brings to the RCA and FMEA, bedside skills and current practice that will improve patient involvement and outcomes. She is involved with patient satisfaction and patient concerns that are not seen by management or the MD.