Organizational Systems and Quality Leadership

Organizational Systems and Quality Leadership

A root cause analysis is an activity conducted by organizations to identify the cause of a problem. Root cause analyses help to identify the issues and identify some solutions that can be implemented to remedy the problem. The analysis acknowledges that some challenges are not straight forward and that it takes the effort of all involved parties to prevent an unwanted outcome. Through interrogating the system, the flaws can be identified and rectified, and adverse events prevented. The purpose of conducting a root cause analysis is identifying the causes of problems and developing solutions to avoid future adverse events and improve health services.

There are six steps to conducting a root cause analysis. The first step is identifying what happened. The people present when an adverse event occurs in the hospital should describe the circumstances surrounding the incident as accurately as they can. Visuals such as flow charts can be used to improve comprehension of events surrounding the events (Institute for Health Improvement, n.d). The team conducting the root cause analysis can interrogate the people involved to understand an event and the circumstances around it. The second step is for the investigating is determining what should have happened in an ideal situation. Once the perfect situation has identified the events of step one; what happened are compared and analyzed critically. Visuals are essential to explain and help understand the two scenarios.

The team conducting the root analysis then moves along to the third step, which is determining what caused the event to happen. Critically questioning the games is done at this stage. At this step, the direct causes and contributory factors are compared. A fishbone diagram is often used to explore and understand the possible causes of specific actions. Various factors influence clinical practice and disease outcomes for patients. The characteristics of the patient, task factors, staff characteristics, the work environment, management and leadership factors are some of the factors that influence a patient’s outcome. By identifying all the influencing factors, the team can link the causes and effects and understand an adverse event occurred and how future adverse effects can be prevented. In this step, the purpose of the game is identified.

Step 4 involves the development of casual statements. The casual statements link the adverse event and the cause. During the process, the contributory factors are identified. When an event occurred, it sets off a chain reaction leading to an effect. Understanding a hospital’s healthcare system will help the department heads and healthcare providers to improve healthcare services as well as disease outcomes for the patients.

Step 5 involves the development of possible actions that can prevent the occurrence of the event in future. Activities to improve health services can be categorized into; strong action, an intermediate action and weak action. Some of the specific interventions looked into include standardization of equipment and checking backup systems or double systems, implementation of functions that can prevent the occurrence of common mistakes by all teams involved in the treatment of patients. The software’s’ should also be updated regularly and implementing simple processes to avoid confusion leading to adverse health outcomes among patients. Policies should also be developed addressing common measures to prevent mistakes in the health facilities and to ensure they are being implemented; the staff should be educated about the policy. Events in the past should be used as learning moments to help healthcare providers improve health services and improve disease outcomes among patients.

Step 6 involves writing a summary and share it with the relevant parties such as department heads and staff. This step will help clarify standard operating procedures by the team to improve health outcomes for their patients.

Application of the root cause analysis involves first identifying the adverse, which in this case is the death of Mr B. The death of Mr B is an outcome that informs on the management of patients in the hospital. The second step involves identification of what should have happened, which is exploration of all possible outcomes for the conditions that Mr B had as well as possible outcomes for the interaction of medication being given to him. The third step is looking at the causes which could have been that Mr B had underlying issues that may have been overlooked by the attending nurse and physician. Mr B laboratory tests indicated he had elevated cholesterol and lipids; it was also identified that he had prostate cancer which can explain his high threshold for pain and incapability of regular pain killers to act for his body weight and age. Some of the causal statements would be, ‘probably Mr B suffered a heart attack due to the high cholesterol and lipids in his body or high dosages of painkillers could have resulted to a heart attack.’

An improvement plan is essential for the healthcare facility to avoid preventable deaths. Some of the practices that can be implemented to prevent adverse events include; development and updating of software that will identify or predict possible actions or events that can lead to adverse health effects on the patient. Continuous review of standard operating procedures in the emergency rooms should be done. The review will ensure that loopholes are identified and sealed hence avoiding unnecessary deaths. Continuous medical education is also essential, consequently ensuring that nurses and other practitioners have evidence-based information which they can use to make medical decisions related to their patients. Listening to the patients is another improvement plan which ensures that the clients get to contribute to ways through which the hospital can serve them better.

Lewin’s theory of change can be applied to the proposed improvement plan. Lewin described the process of change and stages that people undergo before they can implement difference in their lives or organizations. The first stage of evolution in Lewin’s theory is unfreezing stage; in this stage, an organization is learning something new and have to let go and adopt new ways improving service delivery (Sonia Udod, n.d). The department heads and hospital administration will develop new policies and have to involve the staff in ensuring that they implement the new regulations. The team has to let go of former ways of service delivery to the patients and learn new ways and rules to meet the needs of the patients and regulations of the hospital. Adopting new standard operating procedures is the change stage that involves trying out new things. The last stage is the freezing stage that consists in establishing the new policies as a habit. It consists of having the new policies and regulations as everyday activities.

The purpose of failure mode and effects analysis process is to analyze medical processes and procedures in which harm may occur. The analysis predicts where systems might fail and the extent of that failure. With the results from the failure mode and effects analysis process, experts come together and develop solutions before problems can happen.

Complete the FMEA table

Steps in the process

Failure mode

Failure causes

Failure effects

Likelihood of occurrence

Likelihood of detection

severity

Actions to reduce occurrence of failure

Upgrading of software

Software can malfunction

Patient will not receive required medical care

Patient may die

5

9

8

Upgrade software often.

Have a backup for when software malfunctions

Training of healthcare providers

Ignorant healthcare providers

Lack of knowledge

Unmet patients need.

Death of patients

6

8

9

Continuous medical education.

The interventions would be tested by conducting regular check-ups at designated times. The system upgrade will be scheduled at specific times which will ensure that the update happens. Alternative systems and procedures can be provided to ensure that health services don’t shut down. Patients should be able to access healthcare services all the time. Interventions for continuous medical education can be tracked through monitoring the number of training workshops organized by the health facility. Attendance by medical staff will also be monitored to ensure the people meant to attend are attending and learn on how to improve healthcare services and patient management.

Nurses demonstrate leadership in various areas such as promoting quality care, improving patient care and improving quality improvement activities. This is done through taking responsibility of taking care of patients and ensuring that their health improves and they regain their health. Nurses also demonstrate leadership skills by participating in activities that are meant to enhance their skills and grow their knowledge in the management of patients. Nurses also make decisions that influence the outcome of their patients and that point they are acting from a leader’s position.

Nurses participation in root cause analysis and failure modes and effects analysis demonstrates leadership skills. Special teams conduct these analyses, so those selected are like leaders in their disciplines hence the appointment to have extra roles at the hospital. The extra work and effort put the nurses in a leadership position as they move ahead to want to implement the suggestions and improve service delivery to their patients. Nurses are leaders in their discipline of caring for the patient when illness has taken a toll on them, and as leaders, they have to motivate their patients and their families and let them know all will be well.