RCA and FMEA: Improving Patient Outcomes and Quality Care

This article discusses the general purpose of conducting a root cause analysis (RCA) and failure mode and effects analysis (FMEA) process. It also proposes a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome. Additionally, it explains how a professional nurse can competently demonstrate leadership in promoting quality care, improving patient outcomes, and influencing quality improvement activities.

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Running head: RCA and FMEA
Task 2 (1217)
RCA and FMEA

RCA and FMEA
Table of Contents
A. Explain the general purpose of conducting a root cause analysis (RCA)...................................4
100 A1. Explain each of the six steps used to conduct an RCA, as defined by IHI.......................4
100 A2. Apply the RCA process to the scenario to describe the causative and contributing
factors that led to the sentinel event outcome..................................................................................4
B. Propose a process improvement plan that would decrease the likelihood of a reoccurrence of
the scenario outcome.......................................................................................................................5
B1. Discuss how each phase of Lewin’s change theory on the human side of change could be
applied to the proposed improvement plan......................................................................................5
C. Explain the general purpose of the failure mode and effects analysis (FMEA) process............6
C1. Describe the steps of the FMEA process as defined by IHI.....................................................6
C2. Complete the attached FMEA table by appropriately applying the scales of severity,
occurrence, and detection to the process improvement plan proposed in part B............................7
D. Explain how you would test the intervention from the process improvement plan from part B
to improve care................................................................................................................................8
E. Explain how a professional nurse can competently demonstrate leadership in each of the
following areas:...............................................................................................................................8
• Promoting quality care..............................................................................................................8
• Improving patient outcomes......................................................................................................8
• Influencing quality improvement activities...............................................................................9
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E1. Discuss how the involvement of the professional nurse in the RCA and FMEA processes
demonstrates leadership qualities....................................................................................................9
References......................................................................................................................................10
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A Explain the general purpose of conducting a root cause analysis (RCA)
Root Cause Analysis is a kind of systemic approach to solving different problems. Certainly
three major purposes of conducting Root Cause Analysis (RCA) are a physical cause, human
cause, and organizational cause. To identify system flaws and prevent errors to happen, RCA
plays a critical part in an organization. In the case of negligence or willful harm, an RCA is not
applicable. The central feature of RCA includes a focus on system causes rather than blaming.
Moreover, by conducting Root Cause Analysis (RCA), critical system errors can be identified
and resolved (Latino & Latino, 2015).
A1. Explain each of the six steps used to conduct an RCA, as defined by IHI.
Step 1: Identify what happened
In this step, the team needs to clarify information about the event by making a flowchart of what
happened.
Step 2: Determine what should have happened
The team should recognize what happened in ideal conditions by comparing information of the
flowchart.
Step 3: Determine causes
The team must determine direct causes including all contributory factors in this process.
Step 4: Develop casual statements
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The team develops casual statements by explaining how contributory factors influence bad
results for patients and care workers(Fagerhaug&Beltz, 2014).
Step 5: Generate recommended actions to prevent the recurrence of the event
To prevent errors, the team develops an action plan based on the recommendation list, for
example, standard equipment, advanced diagnosis and so on
Step 6: Write a summary and share it
To engage key players for improvement, the team designs a summary by mentioning all actions.
A2. Apply the RCA process to the scenario to describe the causative and contributing
factors that led to the sentinel event outcome.
Based on the provided scenario of Mr. B, it has been assessed that due to negligence such kind of
criticality occurred that led to the death of the patient. The application of the RCA process
integrates-
Step 1- Due to the negligence of the hospital as well as ill-treatment, the criticality in the
condition of Mr. B led to death. The concentration towards the new patients led to negligence
with the health of Mr. B.
Step 2- Nurse J and Dr. T should have provided much care to the patient based on the stats and
medication.
Step 3- The causes are negligence of the patient, wrong medication, poor hospital management.
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Step 4- Due to the negligence of the oxygen saturation level and blood pressure were detraining.
Poor medical advice led to inappropriate sedation. Poor hospital management affected the status
and concentration of the patient.
Step 5-It is recommended to offer effective training to the nurses, constant monitoring to the
severe conditions patients, appropriate medication handling.
Step 6-In order to enhance the situation in future, policies must be reframed about the process of
sedation, constant monitoring of the patient and effective training.
B. Propose a process improvement plan that would decrease the likelihood of a
reoccurrence of the scenario outcome.
The scenario that has been identified in the case of Mr. B was highly critical and required higher
medical attention from nurses and doctors. Effective training to the nurses those are involved in
sedation, appropriate policies must be reframed in the hospital based on negligence, constant
monitoring needs to be provided, and proper medication must be provided based on medical
history, (Westover, 2010). Through these strategies, the likelihood of such reoccurrence would
decrease.
B1. Discuss how each phase of Lewin’s change theory on the human side of change could be
applied to the proposed improvement plan.
Based on Lewin’s change theory, the three stages can be applied to enhance the proposed
improvement plan-
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Unfreeze- Strong support from management, analyzing organizational culture, communicates
the new change with the board members and employees and the concerns and doubts must be
evaluated before the changes in policies. Implement the changes.
Change- Effective communication with the nurses and doctors about the benefits of the new plan
is required, explaining the changes that are required for mitigating such reoccurrence and making
the employees feel comfortable, (Erwin & Garman, 2010).
Refreeze- Initiate strategies to sustain the changes, constant supervision is required as well as
leadership support are required to remove the barriers of sustaining the changes. Effective
support and training are required.
This plan could be effectively implemented in such a manner that the entire framework can be
utilized to analyze the effectiveness of the nurse. This plan would develop and implement key
parameters and then collecting the data and analyzing them effectively to ensure that all the key
parameters have been met.
C. Explain the general purpose of the failure mode and effects analysis (FMEA) process.
The general purpose of Failure Modes and Effects Analysis is to analyze the risk of harm and
failure in processes as well as to determine the essential areas for process enhancement. It offers
strategies for patients’ safeties, medication systems, (Zhao & Bai, 2010). It depicts steps in the
process, failure modes, failure causes as well as effect of the failures which rectifies the flaws in
the current process.
C1. Describe the steps of the FMEA process as defined by IHI.
Based on the IHI, the steps of the FMEA process includes-
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1. Selection of a process for evaluation
2. Recruitment of multidisciplinary team
3. Listing out the steps in the process with the team
4. Listing out failure causes and modes
5. Assigning a numeric value for each mode of failure
6. Evaluation of the results
7. Improvement efforts based on Risk Priority Number
C2. Complete the attached FMEA table by appropriately applying the scales of severity,
occurrence, and detection to the process improvement plan proposed in part B.
Steps in the
Improvemen
t Plan
Process*
Failure Mode Likelihood
of
Occurrenc
e
(1–10)
Likelihood
of
Detection
(1–10)
Severity
(1–10)
Risk Priority Number
(RPN)
1. Sedation
was wrongly
provided.
Wrong
procedure
selected.
4 5 5 80
2. Poor
training led to
immediate
Poor policies and
training
3 4 4 48
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attention. programs.
3. Wrong
medication
was provided
by the doctor.
Negligence 4 5 5 80
4. Lack of
monitoring
and
observance.
Negligence of
nurses and
doctors.
5 6 6 180
Total RPN = 388
D. Explain how you would test the intervention from the process improvement plan from
part B to improve care.
PDSA cycle for the process improvement plan to improve care for patients in the emergency-
Plan- The changes would be made in healthcare policies for improving care for patients with the
integration of the higher management and the team for planning out the recommended strategies
for change as well as to analyze the current gap in the process. Adequate training programs for
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the nurses and specifically choosing the emergency department staffs for enhancing their abilities
and knowledge related to sedation and patient’s medical history.
Do- At first, the emergency department would be provided with education and offer significant
information regarding sedation procedure and attaining appropriate medical history for critical
situations.
Study- After analyzing the feedback of the nurses, an educational handout was also provided to
the nurses who required additional information. The requirement of more information was
identified through the feedback of nurses. Under continuous monitoring, feedback from a few
patients as the trial was also attained for analyzing the gap in the care provided.
Act- The entire team of the emergency department as well as higher management analyzed the
positive impact of the change. However, more care and management of patients in critical
situations need to be provided more thought. The team analyzed that continue testing needs to be
done for the rest of the month with the significant observation regarding the work activities of
nurses to address the issue related to sedation and attaining informed medical history of patients.
Also, more information needs to be provided to the patient about the medical condition which
can be done through relevant PDSA.
Through this PDSA approach, the emergency department followed by another department would
e enhanced based on effective care for patients related to sedation and attaining appropriate
medical history of patients. As stated by (Huczynski et al. 2013), actual change can be analyzed
through measurement. The changes that have been initiated for enhancing the skills and
knowledge of nurses specifically for the emergency department would be measured. It can be
analyzed with the help of a checklist where significant aspects required from staffs and nurses
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would be analyzed based on their work activities such as sedation, patient history collection, and
other relevant aspects. The service to the patients could also be analyzed which would assists to
analyze the gap and to make additional changes in the plan as required. By testing the changes in
a particular department in this case emergency department, the result would be analyzed for its
improvement as well as the requirement to make additional changes in the plan.
E. Explain how a professional nurse can competently demonstrate leadership in each of the
following areas:
• Promoting quality care
By promoting effective care, the professional nurse can demonstrate leadership. Through
leadership attributes constant monitoring of critical patients can be formulated which would
maintain their leadership qualities.
• Improving patient outcomes
The outcomes of the patient would relatively improve with effective training of the nurses by
making them a part in the decision-making process. This would offer a sense of leadership to
them, (Cummings & Worley, 2014).
• Influencing quality improvement activities
The leadership demonstration amongst individual professional nurses would significantly
enhance the improvement in the quality of activities leading to successful patient outcomes as
well as effective care for the patients.
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E1. Discuss how the involvement of the professional nurse in the RCA and FMEA
processes demonstrates leadership qualities.
The involvement of professional nurse would significantly depict leadership qualities in both
RCA and FMEA process. Engaging them in the change process is highly required for making
necessary adjustments and improves their skills, (Jones & Jones, 2013). They are the primary
members that would be affected hence; they need to be in the process of providing effective care
and developing a sense of responsibility.
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References
Erwin, D. G., & Garman, A. N. (2010). Resistance to organizational change: linking research and
practice. Leadership & Organization Development Journal, 31(1), 39-56.
Westover, J. H. (2010). Managing organizational change: Change agent strategies and techniques
to successfully managing the dynamics of stability and change in
organizations. International Journal of Management & Innovation, 2(1).
Huczynski, A., Buchanan, D. A., & Huczynski, A. A. (2013). Organizational behavior (p. 82).
London: Pearson.
Cummings, T. G., & Worley, C. G. (2014). Organization development and change. Cengage
Learning.
Jones, G. R., & Jones, G. R. (2013). Organizational theory, design, and change. Upper Saddle
River, NJ: Pearson.
Fagerhaug, T., & Beltz, M. (2014). Root cause analysis and improvement in the healthcare
sector. Milwaukee, Wis.: ASQ Quality Press.
Latino, R., & Latino, K. (2015). Root cause analysis. Boca Raton, FL: CRC Press.
Zhao, X., & Bai, X. (2010, May). The Application of FMEA method in the Risk Management of
Medical Devices during the Lifecycle. In e-Business and Information System Security
(EBISS), 2010 2nd International Conference on (pp. 1-4). IEEE.
Website
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Failure Modes and Effects Analysis (FMEA) Tool. (2018). Retrieved from
http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx
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