RCA and FMEA a Scenario Analysis

Running head: Organizational Systems Task 2
Organizational Systems and Quality Leadership
Task 2; SAT1-0517
Your Name (without letters or titles)
Western Governors University

Running head: Organizational Systems Task 2
RCA and FMEA a Scenario Analysis
Introduction
Quality leadership enables a healthcare organization to provide high quality and safe health care
to patients. Quality leadership refers to effective promotion of health care through influence of
quality activities that improve patient health outcome. It is a precondition that is used to
implement quality management. Healthcare organizations aim to effectively provide its patients
with quality care that is implemented through quality programs led by teams or managers in
healthcare (Latino, Latino, & Latino, 2016). The effectiveness of an organization system is
dependent on it planning and implementation. An organizational system is a collection of
subsystems that are integrated with an objective of accomplishing an overall goal. Organizational
systems have several stages that enable monitoring and evaluation to ensure an organization
objectives are met by reducing risk and optimizing results. Healthcare organizations credited by
The Joint Commission are required to undertake Root Cause Analysis (RCA) whenever
undesirable events occur in their system and plan an action to improve their system. The
healthcare is then required to conduct failure mode and effects analysis to cause of
system failure to reduce the likelihood of the undesirable even occurring again. The
following write up discusses the root cause analysis and failure mode and effects analysis a case
study of Sixty-bed rural hospital.
A. Root Cause Analysis (RCA)
Root cause analysis (RCA) provides a framework for comprehensive systematic analysis of a
scenario. RCA is defined as process that identifies the basic or causal factor that lead to variation
in performance (Charles et al., 2017). The variation in performance lead to undesirable or
unexpected outcomes those are adverse. Root cause includes risks or occurrences of a sentinel
event that reach a patient that result to permanent harm, death or severe but temporary harm. The
root cause analysis focuses on organization systems and processes. The analysis does not focus
on individual performance to assign blame but determines process that a team works on with an
objective of understanding a process or processes that cause or have potential to cause variations
in outcome expected or desired (Brook, Kruskal, Eisenberg, & Larson, 2015). The purpose of

Running head: Organizational Systems Task 2
RCA is therefore to find the fundamental reason that cause or can lead to failure. The RCA also
identifies process change that can be implemented to reduce error and continuously maintain and
improve the quality of health care delivery.
A1. RCA Steps
The RCA uses a systematic approach to analyze an event that has six steps. Each step build on
progressively understanding the cause and identifying what be done in the system to correct and
prevent an error from happening (Stang et al., 2018). The first step of RCA is identifying what
happened. This step describes what accurately and completely happened. The team organizes and
clarifies information that relates to the event to allow visualize what occurred that led to the
unexpected or undesirable outcome (Lee, Mills, Neily, & Hemphill, 2014). The second step of
RCA is determining what should have happened in an ideal condition. In this step, the team
involved in the RCA determines the processes that would have been taken in an ideal condition
hence preventing an occurrence of an error in the system. The third step in RCA is determining
causes. This step is very important to outlining contributing factors that led to the event. The
team “asks why question five times” that enable to look directly to causes and contributing
factors in the scenario (Peerally, Carr, Waring, & Dixon-Woods, 2017). The third step therefore
outline the root causes of the event by exhaustively question the processes. The fourth step of
RCA involves developing a causal statement. The casual statement link identifies causes in step
three to effects and then to main event. The causal statements explain how contributory factors
are factual to the current situation and how they contribute to undesirable or unexpected
outcomes in the healthcare. The casual statements have three parts that are cause, effects, and
event. The fifth step of RCA process is generating list of actions that are recommended to change
and prevent reoccurrence of the undesirable event. The recommendations are actions that the
team thinks that they can help prevent errors from occurring again in the system. The sixth and
last step of RCA is writing summary and disseminating findings. This step is important for
engaging with other key stakeholders in the process of driving improvement in the system. The
RCA process therefore systematically and objectively defines causes that lead to sentinel events