The general purpose of performing root cause analysis (RCA) in healthcare is to identify the fundamental factors that cause a discrepancy in performance and explore the reasons sentinel events occur. According to Brook, Kruskal, Eisenberg, and Larson (2015), RCA in healthcare is applicable in uncovering the possible causes, factors, and events that affect patient safety to enable the organizations to enhance the delivery of safe care by developing corrective measures.
Institute for Health Improvement (IHI) Six Steps for Conducting RCA
Step 1: Gathering Facts and establishing the team
The step entails reviewing the documents associated with the event. In a healthcare setup, the materials include an incident report and patient information as recorded in the electronic health records. The other activity in the first step is the establishment of the RCA team which includes the interdisciplinary staff members in direct contact with the incident, experts, administrators and physician champions. Other procedures in the initial step include creating event timeline, obtaining the RCA flowchart and establishing procedures, policies, and rules that govern the RCA team and the whole process (IHI, 2017).
Step 2: Understanding what happened
The stage begins with collecting and organizing facts about the occurrence to aid in the analysis of the event hence understanding what happened. In the presence of all the team members, there is a thorough review of the occurrence with the aim of comparing the associated event sequence with the organizations guidelines, best practices, procedures, and policies. Ideas and opportunities begin to come up, and it is essential to document them.
Step 3: Determining the root causes and the contributing factors
The step has the basis of analyzing the event process to brainstorm the key reasons behind the occurrence of the event. This third phase aims at answering the question why followed by the categorization of the causes into various classes. The possible categories of the roots causes of a sentinel event in healthcare include human factors such as staffing, fatigue, and communication, environmental factors, information management, and corporate issues in procedures, policies, and rules (IHI, 2017). The roots causes are the underlying conditions surrounding the events which upon correction will prevent the recurrence of an event. On the other hand, contributing factors are those that will not solve the issues even if they are corrected and can trigger unwanted events in future.
Step 4: Risk Reduction Plan
The step entails developing risk mitigation strategy in which the team members identify the probable corrective measures for every root and contributing cause and their respective improvement opportunities.
Step 5: Evaluating the effectiveness of the actions
The step entails the analysis of the action plans to assess their effectiveness. It involves the evaluation of the whole RCA process. The investigation should ascertain whether the effects reduce the chances of the event recurring.
Step 6: Reporting
It is the final action which entails the process of reporting the outcomes and the activities to the organizations leadership and quality oversight board.
Applying RCA to the scenario
The facts in the hospital setting include:
Facility size: six rooms with a holding capacity of sixty beds.
Staffing: one registered nurse (RN), one licensed practical nurse (LPN) and one physician in the emergency department.
Mr. Bs symptoms: chronic pain recorded as 10/10 in the pain scale, prostate cancer, and poor glucose tolerance.
Other facts: Mr. B. was left unmonitored as the health professions rush to attend an incoming patient in the emergency lobby. The staff was also caring a patient with a pain scale of 4/10 instead of prioritizing Mr. B. There was congestion at the hospitals emergency lobby. Other patients were not discharged but left waiting while others had pending laboratory results. Mr. B finally dies despite resuscitation attempts.
Time line- The RCA process will take two weeks.
Mr. B died when Nurse J and Dr. T were busy attending another patient in the emergency room. During the Mr. B.s last moments, his son was monitoring him. The Nurse J returns when the oxygen saturation is 79%, and the patients blood pressure level is 58/30 from 92% and 110/62 respectively before leaving the room with the doctor.
Staffing problem: one registered nurse (RN), one licensed practical nurse (LPN) and one physician in a sixty-bed emergency room is a severe workforce staffing issue.
Emergency lobby congestion: There was congestion in the emergency lobby area which is responsible for the seamless movement and access to all the patient rooms as Nurse J took time to move to Mr. Bs bed to others.
Patient negligence: Close monitoring of the Mr. Bs condition required the ever-presence of the nurse according to the hospitals analgesia and sedation policy. It was not ethical for the nurse to delegate monitoring function to Mr. Bs son.
Inefficiency in healthcare delivery: The congestion on the emergency lobby is due to the ineffectiveness in delivering care evident from the two patients with pending laboratory results and discharge order.
The risk reduction plan includes increasing the hospitals workforce, patient prioritization, increased teamwork and greater accountability of the patients health and well-being to reduce negligence.
The activities carried out in the phase include evaluating the effectiveness of the actions taken. Measurements include the observation of the emergency lobby for determining congestion by recording the number of people in the area. On the other hand, the evaluation of the efficiency of the staff is such that there should be an efficient flow of patients in and out of the facility without delays and pending laboratory results.
The step entails the documentation of the countermeasures and reporting the need for changes such as increased staffing, restructuring the emergency lobby to reduced congestion to the hospitals leadership.
Lewins change theory in the proposed improvement plan.
The stage entails making the facility management understand the need for change (Cummings, Bridgman, & Brown, 2016). In the scenario, the phase will involve demonstrating to the hospital leadership that Mr. Bs death accrued from staffing problem as the contributing factors for the death include lack of close monitoring of the patient as both Nurse J and Dr. T was committed to another patient. Increasing the hospital workforce can allow patient prioritization such as attending to Mr. B whose pain scale is 10/10. The standard RN-patient ratio should be 1: 6-10 to satisfy patient needs.
The step entails incorporating changes as part of the facilitys daily operations. The procedures necessary in the scenario following the step is the intake of new nurses and physicians, coaching and training about patient negligence and adherence to the hospitals internal policy, procedures, and guidelines.
In the scenario entails achieving stability and ensuring seamless integration of the changes in the proper functioning of the hospital after introducing the changes (Cummings, Bridgman, & Brown, 2016). Close monitoring of the patients with chronic patients as part of the facilitys policy and accepted norm should take effect upon introduction. As the changes entail the addition of more health professional, the phase encompasses overseeing how the workers form a new relationship with the newcomers being comfortable working in teams with others.
The general purpose of conducting a FMEA is to detect potential failures existing within a given process or product design to obtain options and opportunities for mitigating the risks accruing from the impaired process (IHI, 2017).
Step 1: Assembling FMEA team and conducting a FMEA pre-work
The pre-work activities in the FMEA process entail the team collecting and creating primary, preparatory documents such as flow diagram of the process and the characteristic matrix. The step requires the identification of the potential effects and failures (IHI, 2017).
Step 2: Determination of the severity
The stage is also known severity ranking phase as it entails gauging how severe the failures are. There is an insertion of the severity rankings, failure effects, and modes into the FMEA process.
Step 3: Conducting occurrence ranking to indicate the causes and possible prevention controls
The step involves the selection of the causes of process or design failures followed by placing them into respective cause column with each column containing occurrence ranking. Quality-One Criticality Matrix provides actions formed to solve issues that have high-risk occurrence and severity (IHI, 2017).
Step 4: Detection ranking
The stage encompasses the addition of detection and testing controls. The role of this phase is to ensure that prevention controls meet the requirements.
Step 5: Action priority
FMEA activities in this stage involve assigning risk priority number (RPN) to every action. The assignment operation similarly entails delegating appropriate personnel actions plan and forming due date for each action.
Step 6: Taking measures and evaluation of the results
The step requires the application of counter measures for successfully reducing the risks hence fulfilling the primary role of FMEA of discovering and mitigating the risks (Latino, 2009).
Step 7: Re-ranking risk priority number (RPN)
The step occurs after successfully confirming the proposed risk mitigation plans hence re-ranking the suitable detection, occurrence and severity ranking value. It entails carrying a comparison analysis of the revised and original RPN to evaluate the relative enhancement of the process.
Steps in the Improvement Plan Process Failure Mode Likelihood of Occurrence(110) Probability of Detection(110) Severity
(1-10) Risk Priority Number
Step 4 Patient negligence 4 5 7 140
Step 5 Inadequate staffing 4 5 5 100
Step 6 Lack of patient prioritization 3 6 5 90
Step 7 Lack of prompt resuscitative care 4 5 8 160
Total RPNs 490
Explain how you would test the interventions from the process improvement plan from part B to improve care.
The outlines interventions for the scenario include increasing the hospitals workforce, patient prioritization, improving teamwork, and increasing accountability for the patients health and well-being to reduce negligence (Latino, 2009). For the first intervention, testing the adequacy of the workforce entail the calculation of the nurse-patient ratio. The hospital can hold up to sixty individual hence the standard number of nurses should be ten to achieve the 1:6 ratio. On the other hand, testing patient prioritization is through observing the numerical pain scale of the patients that nurse give priority. Testing accountability is through finding documented incidences which nurses became negligent.
Professional nurse demonstrating leadership in:
Promoting quality care
According to Murphy, Quillinan, and Carolan (2015), nurse leaders are knowledgeable hence they demonstrate leadership through the provision of insights to the junior staff on the ways of demystifying patients clinical experience, interpretation health information and navigating the health care delivery. As the nurses perform functions such as surveillance and monitoring to prevent the occurrence of errors, they demonstrate leadership in the promotion of quality care is hence acting as crucial elements...
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