Root Cause Analysis and Failure Modes and Effects Analysis in Healthcare, Thesis of Business Accounting

Download Root Cause Analysis and Failure Modes and Effects Analysis in Healthcare and more Thesis Business Accounting in PDF only on Docsity! C-489 Organizational Systems and Quality Leadership Task 2 Western Governors University A. Root Cause Analysis (RCA) Root Cause Analysis (RCA) is a tool used within healthcare to aid in the discussion and prevention of errors that may have happened. A group of individuals discusses what and why a situation occurred but also helps to formulate a plan in which to prevent it from happening again instead of focusing on who was involved. Root Cause Analysis has an aim to “build a culture of safety and move beyond the culture of blame” (U.S. Department of Veterans Affairs, n.d.). By further looking into how and why events occur healthcare systems are better equipped to prevent future incidences from occurring. A1. RCA Steps Step One: Identify what happened The panel must determine what exactly took place and in doing so must also make sure that all details are included and accurate. To better understand the information flowcharts or pictorials are often used to aid in the visualization of the event. Step Two: Determine what should have happened The panel will then discuss what should have happened to achieve the optimal results. In this stage, another flowchart can be used with the correct policies or procedures listed so that the team may look at the chart from step one and compare. Step Three: Determine the cause During this step, the team looks at factors that lead to the error both directly and contributory. A fishbone diagram is often used during this phase of the process to better visualize the cause and effect flow. RCAs recommend asking “why” repeatedly to determine the exact cause of the problem being discussed. Step Four: Develop causal statements The main purpose of developing a causal statement is to add links between the cause that was determined in step three to the outcome and then back to the main event that initiated the RCA. These statements give explanations on how events arose and aid in the implementation of changes to policies and procedures to prevent future incidences. Step Five: Create a checklist of recommended actions to avert repeating the issue Create a list of actions to aid in the prevention of recurrence of the event being discussed. Included in this list can be issues such as simplifying processes, the use of a checklist, standardizing policies, and also repeating procedures to ensure compliance. Timelines should be created to determine if policy changes are effective or if further revisions are necessary. Recommendations for change may include:  Standardizing equipment  Ensuring repetition (using backup systems/double checks)  Improving/updating software  Making new policies  Employing hard stops which aid to hinder users from making repeated errors  Continued staff training  Providing aids such as mnemonic devices, illustrations, and lists  Establishing new policies or staff member from the ED. The next in the process is to determine exactly what happened as thoroughly as possible by interviewing those involved in the incident. Along with interviews, charting can be reviewed to create a detailed flow chart of all events that took place based on all information collected. Upon reviewing this information the team can then determine what should have occurred to prevent this event from transpiring. The team can then construct another flow chart based on this information to have a side-by-side comparison of the events that took place and those that should have occurred. At this point, the team will also ask “why” repeatedly to determine the exact cause of the events in question. Next, a causal statement is formed by the team which discusses the cause, effect, and event. The fifth step in the process would be coming up with suggestions to aid in the prevention of future occurrences of the problem at hand. Lastly, the team will formulate a synopsis of the RCA and disburse it to management, staff, investors, and other colleagues. Provided in the synopsis could be recommended safety checklist for the administration of sedatives to make sure important vital sign monitoring takes place and also proper staffing ratios with the use of flex/float pool nurses during busy times. B1. Change Theory In 1950 Kurt Lewin developed a tool in which to aid in change management. Lewin’s change theory was made up of three steps. The first step in the process is to unfreeze in which things are set up to prepare for the change desired. The second is titled change and this is where the necessary changes are set in motion. Lastly, is refreeze where you solidify the desired change (Mulder, 2012). In the unfreezing phase, awareness is brought to the change in question to help people understand why this particular change is necessary. The process improvement team should educate employees about the sentinel event and what policies/procedures lead to this occurrence, hence the need for change. The team then initiates these changes, including sedation safety guidelines, staffing ratios, and a checklist. Once the staff has been introduced to the new modifications, the team can then begin the unfreezing phase where necessary changes are set into motion. During this stage, the new policies regarding monitoring during sedation and safe staff ratios will immediately take effect and should become part of the staff’s everyday practice. During this time the staff must have management available for support and further education regarding new policies and procedures being put into place. C. General Purpose of FMEA Failure Modes and Effects Analysis (FMEA) is used to aid in the identification of possible failures. Healthcare systems use this to improve the quality of care and also to decrease damaging inaccuracies (Failure modes and effects analysis tools, n.d.). In using this tool the team is then able to review, evaluate, and record information in the following way:  Steps in the process  Failure modes/What could go wrong?  Failure causes/Why would the failure occur?  Failure effects/What would be the consequences of each failure? C1. Steps of FMEA Process There are seven steps listed in the FMEA process. The first step is to determine what you are assessing using FMEA. Second, a multidisciplinary team is established to carry out the process. The third step is to establish a list of all points in the process to be evaluated. Fourthly, possible failure modes are identified by the team members. Fifth, risk priority numbers (RPN) are assigned to each failure mode the represent the possibility of reoccurrence, the possibility of detection, and how severe the failure was. In the last step in the process, the team then evaluates the RPN to plan for improvement. C2. FMEA Table See additional attachment for the table. D. Intervention Testing The improvement process has tested the suggestions for change must first be implemented. The changes that must be made are staffing ratios, medication safety, and proper vital sign monitoring. Random chart analysis can be performed to determine if checklists are being used as recommended in the change. Upon review, if it is determined that checklists are not being used as recommended then modifications can be made. This process is then repeated until it is determined that proper usage is occurring. When assessing staffing ratios, charts can be made to monitor and determine when the ED experiences the highest volume of patients. In doing this there will be a better understanding of the staffing needs to avoid possible negative events from occurring while increasing patient and staff satisfaction at the same time. E. Demonstrate Leadership Promoting Quality Care Promoting quality care can be demonstrated in the leadership of professional nurses by improving the standards of care. Quality of care occurs when the proper policies are in place and when the nurses are held to these policies. Nurses can help formulate and rewrite current policies based on continued research and evidence-based practice skills to improve patient quality of care.