ORGANIZATIONAL AND QUALITY LEADERSHIP

Organizational Systems and Quality Leadership
Task 2; SAT1-0517
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Organizational Systems and Quality Leadership Task 2; SAT1-0517
A. Root Cause Analysis
A root cause analysis is viewed as an approach that assesses the what, why, and how of an event to advance the safety of a given system. It puts into consideration the causes and errors that resulted in the occurrence of a sentinel situation (Jones & Despotou, 2016). As per the case study, the Sentinel situation was the death of a patient. The analysis focuses on decreasing errors rather than looking for parties to place the blame on.

A1. RCA Steps
The first step involves the identification of what occurred in an event. The second step consists in determining what is expected to have happened. The third step entails identifying the causes. The fourth step involves developing the causal statements while the fifth step consists of the identification of recommendations by the medical team (Jones & Despotou, 2016).
A2. Causative and Contributing Factors
The sentinel situation entailed respiratory arrest and the conscious sedation procedure. Some of the factors that led to the event include inadequate staffing, high patient ratio, and the patient not being monitored as expected. Other factors include the absence of supplemental oxygen before the procedure and alarms being disregarded by the members of staff.
B. Improvement Plan
There is the need to establish a committee to ascertain the implementation of change regarding the process associated with conscious sedation.

It is also important to increase the number of nursing staff and to have flex nurses who will ensure that a patient is frequently monitored.

B1. Change Theory
Change theory refers to an overall perspective on a change that is considered to be useful in formulating ideas that may facilitate improvement. Once a change takes place in the medical setting, there is the need to examine the issues affiliated to the difference.

C. General Purpose of FMEA
The Failure modes and effects analysis or (FEMA) is an approach whose primary purpose is to assess, identify and get rid of possible errors and failures linked to a processor system (Institute for Quality Healthcare Improvement, 2004).
C1. Steps of FMEA Process
The first step entails defining the topic and identifying the team members. The second step causes brainstorming for issues that result in the concern. The third step is to determine the problems highlighted in the failure mode. Step four involves providing an estimation of the degree of damage when a failure occurs. Step five consists in assigning a frequency setting while step six consists of analyzing the possible failure. Phase 7 entails computing the Risk Priority Number affiliated with each failure mode. Step 8 involves the prioritization of the actions affiliated with the failure modes by the team. Phase 9 consists of taking action to eliminate the failure modes while the last step includes calculating the RPN (Institute for Quality Healthcare Improvement, 2004).
C2. FMEA TableSteps in the Improvement Plan Process * Failure Mode Likelihood of Occurrence(1–10) Probability of Detection(1–10) Severity
(1–10) Risk Priority Number
(RPN)
EXAMPLE:
Nurses ordered to monitor the patient in the emergency room…
Lack of support between nurses in the emergency room 7 5 10 75
1.select the process that needs evaluation 2.identify and select a team 3.the teams meeting to discuss the process 4.the team meeting to identify the failure modes and the associated causes Total RPN (sum of all RPN’s):
*do not include more than four steps in the improvement plan process
D. Intervention Testing
On intervention testing, three factors come into perspective that includes; the severity of the damage experienced by an individual, the possibility of a problem taking place and the manner in which an issue can be easily detected. The approach to consider is the Plan-Do-Study-Act that involves planning, attempting the change, making a note of the results and acting basing on the information obtained from the process.

E. Demonstrate Leadership
The type of leadership skill to consider is collaborating with others to ensure that a change is successfully implemented.
E1. Involving Professional Nurse in RCA and FMEA Processes
A professional nurse to consider is the emergency room nurse whose focus is on the improvement of quality and educating the other members of staff on issues associated with the emergency room.

F. Sources
References
Institute for Quality Healthcare Improvement, (2004). Failure modes and effects analysis (FMEA) tool. Retrieved from http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx
Jones, R. & Despotou, G. (2016). Root Cause Analysis and Health Informatics. Studies in health technology and informatics, 226, 131-134. 10.3233/978-1-61499-664-4-131.