Root Cause Analysis, Change Theory, and Failure Modes and Effects Analysis in Healthcare Organizations, Thesis of Management Accounting

Download Root Cause Analysis, Change Theory, and Failure Modes and Effects Analysis in Healthcare Organizations and more Thesis Management Accounting in PDF only on Docsity! C489 Organizational System and Quality Leadership Western Governors University A. Root Cause Analysis The general purpose of root cause analysis is a tool and technique or strategy in the healthcare organization to analyze sentinel events, identify the root cause, and implement solutions to improve patient safety by preventing future harm. The healthcare goal is to use the RCA method to determine the effectiveness and efficient ways of measuring and improving performance in the reality of incidence and provide a structured problem-solving to determine what happened, why it happened, and how to decrease the likelihood of the event from reoccurring (National Patient Safety Foundation, 2015). A1. Root Causes Analysis (RCA) steps The RCA steps: 1. Identify what happened This first step of RCA is when the organization's professional team will investigate the event's contributing factors by creating a flow chart. This flow chart is to help or allow the team to visualize the event. 2. Determine what should have happened The team experts will analyze the collected data that contributed to the problem. It is beneficial to organize and clarify information to create a further flow chart based on the data collection and compare it to step one. 3. Determine causes (“Ask why five times"). This step is when the team will identify the created flow chart problems with all the possible causal factors and dig deeper into how it started. The professional RCA team will "ask why five times" to determine all possible consequences and gather details of the underlying root cause by breaking down the problem into smaller and grouping them using the fishbone diagram. These seven different factors influence clinical practice, and medical error includes:  patient characteristics  task factors  individual staff member  team factors  work environment  organizational and management factors  Institutional context. 4. Develop a causal statement This causal statement uses the same tool that was identified and contributed cause and effect in step 3. This causal statement has three parts: 1. The cause "this happened..." 2. The effect ("... which led to something else happening.” 3. The event (" which caused this undesirable outcome"). 5. Generate a list of recommended actions to prevent the recurrence of the event. recommendations to prevent the sentinel events from reoccurring in the future. Lastly, the team will write a summary and share it with the team to facilitate leadership with staffing and other disciplines affected by the event and implement a proposal of recommendation and build a strong organization. Some possible recommendation for this scenario includes providing adequate staffing, ensuring the proper dosing with medication by inquiring to the pharmacist, implementing the sedation safety guidelines such as continuous BP monitoring, ECG, continuous pulse ox monitoring, immediately report any critical findings to the physician, and create strong teamwork to assess, reassess, and evaluate the condition to improve quality of care and deliver safety to the patient and the hospital organization. B1. Change of Theory There are three stages of Lewin's change theory: 1. Unfreezing stage 2. Moving stage 3. Refreezing stage The unfreezing stage is essential in recognizing the need for a change, determining what needs to be done, encouraging, adapting, and understanding others' change of behavior, ensuring a strong team and management. This stage is difficult and stressful because it involves people in the organization who may evoke a strong reaction to what exactly of changes that are being. The Unfreezing stage is a great time to educate staff on upcoming changes or new policies including following a sedation safety checklist or guidelines. This stage will help the team improve awareness, patient and staffing safety, and the change of current practice. The moving stage is when the change has been implemented, including the organization's change and behavior, and helps staff learn a new concept, planning, and leadership. Individuals may take time to understand and embrace the new transition that may benefit the organization and the staff. Implementing sedation safety guidelines, including continuous BP monitoring, ECG placement, and monitoring, pulse ox monitoring, reporting any abnormal findings to the physicians and RN. Adequate staffing with the knowledge and skills to recognize and treat complications, and recovery care. Lastly is the refreezing stage. This stage has been stabilized, reinforced, and the change has been sustained and succeeded. Implementation of new changes on the organization's recommendations by maintaining and following safety guidelines, providing adequate staff, and building a strong team will reduce errors in the future by evaluating chart audits, staff yearly competency check, maintaining current certification in basic life support, and delivering standard techniques related to sedation medication to promote safety and effective care. C. General Purpose of Failure Modes and Effects Analysis (FMEA) Failure Modes and Effects Analysis's general purpose is to identify potential failures that may happen where, how, and to what extent the system might fail. The healthcare system to emphasize prevention may reduce the risk of harm to both patients and staff. The team will use appropriate experts to work together and implement those failures to enhance patient care, improve staff, and the organization. ( Failure modes and Effect Analysis tools, n.d). The following FMEA tools prompt the team to review, evaluate, and record:  Steps in the process  Failure modes( What could go wrong?)  Failure causes (Why would the failure happen?)  Failure effects (What would be the consequences of each failure?) C1. The FMEA process The process of FMEA is, to begin with, an evaluation. The second is to recruit a multidisciplinary team. The third is to have the team list all the steps to process the evaluation. Fourth is having the team to identify potential modes of failure. The fifth is the team action plan appointing risk priority numbers to each failure mode representing the likelihood to occur, the likelihood of detection, and the cause of severity that are likely to occur. Sixth is to allow the team to evaluate the result that impacts the environment and prepare for a change. The last process is to use the RPN to set a plan and goal of improvement. C2. FMEA Table List 4 steps in Improvement Plan Process List 1 failure Mode per Step Likelihood of Occurrence (1-10) Likelihood of Detection (1-10) Severity (1-10) Priority Number (RPN) 1. Adequate staffing with an inappropriate patient ratio Failure to get help from other nursing staff or resources 5 6 4 120 2. Report the patient's change of condition. Positive communication techniques reduce conflict. Failure to Report immediate abnormal findings to RN and physicians. 5 6 10 300 3. Implementing policies and guidelines regarding the continuous Failure to provide adequate training and education to staff. 6 5 6 180