Root Cause Analysis and Process Improvement Plan in Healthcare

This article discusses the purpose of conducting root cause analysis (RCA) and the six steps of the RCA process. It also covers the process improvement plan and how a professional nurse can demonstrate leadership in promoting quality care. The article provides insights into the failure mode and effect analysis (FMEA) and its steps. Finally, it talks about testing the intervention of increasing the number of staff working per shift in the hospital and evaluating the efficiency of services at the hospital.

ORGANIZATIONAL SYSTEMS AND QUALITY LEADERSHIP
Name
Institutional Affiliation

Purpose of conducting root cause analysis (RCA)
Root cause analysis is a problem-solving method that is used for identifying the root
cause of a problem. A factor is considered a root cause if removal of the factor will
prevent undesirable outcome from recurring. Root cause analysis is conducted with
the objective of identifying the leading cause of a problem rather than merely
addressing the symptoms of the problem (Leonard, Joint Commission Resources &
Institute for Healthcare Improvement, 2013). After identifying the root cause, it is
possible to find a solution to the problem and hence ensure the problem does not
occur again.
Six steps of the RCA process
The following are the six steps followed when performing RCA as defined by IHI;
The first step of conducting RCA is fact gathering using a timeline and interviews.
This step requires the facilitator/investigator to review documents that are related to
the event. Such records may include medical reports and incident reports. For our case
study with nurse J who was taking care of patient B, an interview will be arranged
with both the nurse and the family of the diseased to help investigate the events that
led to the undesired situation (Myers, 2012). Medical records from the hospital and

the facility in which the patient was transferred will also be investigated to provide
information on what could have happened. The standard policy of the hospital was
that a patient who is sedated should remain on continuous B/P, ECG and pulse
oximeter until the patient meets the specific discharge criteria. The team needs to
investigate why standard procedure and policy was not followed on this patient.
The second step understands what happens. In this step, the facilitator or the person
investigating the incident should review established timelines with everyone in the
team (Hay, Levin, Deterding & Abzug, 2014). The team should then compare the
schedule of events with the actual sequence of events that should be followed
according to the policy or best practice guidelines. Patient B was left on automatic
blood pressure machine with his son. Standard procedure and systems of the hospital
require that such a patient should never be left alone and they should always be under
the care of a registered nurse. Nurse J was also allocated so many patients on that
night despite there being backup staff in the hospital. The nurse was well trained in
sedation training module and was well qualified. The nurse also did not have a history
of negligent patient care.
The third step is the determination of the root causes. The team, based on the analysis
carried out in the previous step brainstorms the root cause of the problem by asking
questions such as Why? How? The causal factors are categorised, and then the
contributing factors which would not prevent recurrence but are significant are
isolated and listed. One of the possible causes of the unfortunate event is that nurse J
failed to follow the policies and procedures laid down by the hospital management.
Step four is developing casual statements. A casual statement links the identified
causes to the effect of the problem and then to the event that prompted RCA. The
casual statements explain how contributory factors contribute to undesirable outcomes

(Marshall, 2010). The problem might have occurred because poor communication
between doctor T and nurse J. The other nurses who were supposed to be on duty that
night may have failed to report to work and hence overwhelming nurse J with a lot of
work. The negligence of the nurse might have contributed to the death of patient B.
The fifth step is generating recommended actions which will help in solving the
problem. Some recommended actions are more effective than others. The National
Center for Patient Safety classifies the actions into robust, intermediate and weak
actions. Nurse J can be offered additional training to prevent recurrence of the event.
More nurses should be on duty to help handle emergencies.
Step six of the process involves writing up a summary and sharing it with the relevant
audience. This is an excellent opportunity to clarify information about the event and
present the recommendation so that they can be implemented.
B. Process improvement plan
To come up with a process improvement plan, an audit should be conducted to
identify the exact areas that need improvement. An independent review should be
undertaken to determine the number of nurses on duty at each given time. This is then
compared to the required standards regarding staffing. Customers will also be
interviewed to determine their level of satisfaction and take appropriate action.
Step 1: Increase the number of nurses for each shift
Step 2: Increase the number of doctors working in the emergency department.
Step 3: Offer staff additional training to help them understand how to deal with
pressure at the workplace.
Step 4: Improve communication among the medical staff
1) Lewin change process

Unfreeze-The management of the hospital should make a random change in staffing at
the hospital and redesign how activities are run at the facility. The hospital should
increase staff in each department and change the work routines to ensure nurses are
available in case there are many patients who need emergency care.
Change- Build stability after staff at the hospital has opened up their mind on the
change. During this stage, both nurses and doctors will have started getting adapting
to new roles and tasks (Joint Commission Resources, Inc, 2017). The hospital
management should carry out monitoring to ensure the new changes in scheduling and
training adheres consistently.
Freeze- This will involve making the change stick and become a routine at the
workplace. Staff will get used to the changes and implementation will be easier and
hence ensure undesired circumstances do not occur again in future.
C)
The purpose of failure mode and effect analysis is to study the reliability of systems
in an organization and identify how and why the systems might fail.
1)FMEA involves the following steps:
Step 1: Select a process to evaluate with FMEA. This involves selecting a specific
process that should be evaluated (Malloch, 2017). The process should be simple and
should not have so many sub-processes.
Step2; Recruit a multidisciplinary team. All the people involved in the event should
be included in this team. This will help in collecting all the vital information that is
critical for analysis. Nurses, Doctors at the ED, receptionist and the hospital
management should be involved in this process.
Step 3: Have the team meet together to list all of the steps in the process. Every step
in the process should be numbered and a flowchart designed to help in outlining each

step.
Step Four; Listing failure modes and causes. In this step, the team lists all things that
went wrong and then identifying what could have caused each of the problems.
Step Five: For each failure mode, assign a risk priority factor(RPN). The likelihood of
each event occurring is assessed, and so that focus can be put on more risk factors
(Rohde & HCPro,2014).
Steps in the
Improvement
Plan Process*
Failure Mode Likelihood of
Occurrence
(1–10)
Likelihood of
Detection
(1–10)
Severity
(1–10)
Risk Priority
Number
(RPN)
EXAMPLE:
Doctor orders
medication
for pain prior
to invasive
procedure.
Wrong medication
selected
3 5 5 75
1.Increase
number of
nurses per
shift
The nurse and the
doctor at the ED were
overworked hence
resulting to fatigue
3 5 4 60
2.Increase
number of
nurses in ED.
Insufficient financial
resources
7 5 7 80
3. Offer staff
additional
training
Neglect of patient and
breakdown in
communication
3 4 3 55
4.Improve
communicati
on among the
staff
Failure to communicate
effectively and poor
procedures and
processes
4 3 4 65
Step six: Evaluation of RPN results.
Step seven: Use RPN to plan improvement efforts. Failure modes with high RPN
should be given more priority since they are more likely to occur. By focusing on
these, the hospital will be able to avoid an occurrence like the one that happened with

Mr B.
D)
I would test the intervention of increasing the number of staff working per shift in the
hospital by carrying out a weakly and monthly audit on the number of nurses on duty
at each particular time. The efficiency of services at the hospital will be evaluated by
determining the number of doctors in the emergency department (Crowell, 2016).
Weakly surveys will be conducted in each department at the hospital with the
objective of obtaining feedback on the quality of services they received from the
medical staff in the hospital. The results of the audit would guide us in determining
the actions to be taken to avoid the occurrence of a similar situation.
E)
A professional nurse can demonstrate leadership in promoting quality care by

involving patients and their families in making decisions about their health (Vanden
& ABS Consulting, 2008) This is important since it offers patients a chance to choose
on what is right for them and hence ensure that they get the best quality health care.
Another way in which a nurse can demonstrate leadership is undertaking continuous
monitoring and assessment of the patient to address complications and reduce risks.
Nurses also educate family members and patients for discharge to reduce the risk of
the patient getting ill again.
The nurse can demonstrate leadership in improving patient outcomes by promoting
well-informed diagnosis to ensure high-quality treatment. Nurses should also support
optimal treatment planning. Transparency will also improve patient outcomes at the
hospital. A nurse can demonstrate leadership in improving patient outcomes by
showing concern and respect for patients as well as fellow workers. This helps in
creating trust and hence bringing about motivation. A nurse can also demonstrate
leadership by being task oriented and providing direction and clarification of tasks.
Leadership in quality improvement process can be demonstrated by nursing engaging
in training and development activities. This will help in increasing knowledge and
equipping nurses with skills required to handle complex medical situations. Processes
can be improved at the hospital by increasing the number of staff working during each
shift. Nurses should engage in research consistently to identify any necessary change
and identify models for improvement. Designing an evaluation plan will also be
important in the quality improvement process.

Reference list
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and techniques.
Leonard, M., Joint Commission Resources, Inc., & Institute for Healthcare
Improvement. (2013). The essential guide for patient safety officers. Oakbrook
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Malloch, K. (2017). Quantum leadership: creating sustainable value in health care.
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to influential leader. New York, NY: Springer.
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Timmins, N. (2015). The practice of system leadership: Being comfortable with
chaos.
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