NSG C489 SAT Task 2.

Running Head: ORGANIZATIONAL SYSTEMS TASK 2 1 NSG C489 SAT Task 2. Organizational Systems and Quality Leadership SAT Task 2 Lori Volpe Western Governors University A. Root Cause Analysis The purpose of a root cause analysis (RCA) is for an organization to better gain an understanding of why an adverse occurred by examining system-wide problems or breakdown in an organization’s process rather than a way to assign blame to a single person or group of people. An RCA is done retrospectively as it is triggered by the event occurring. By following the necessary steps to examine the true reason why an event occurred, as well as putting interventions in place to correct the process breakdown, an RCA can prevent the error from happening again (Institute for Healthcare Improvement, n.d.). A1. RCA Steps There are six steps necessary for the RCA to be an effective tool that results in process or organizational changes to prevent a reoccurrence of the event that triggered the RCA in the first place. These steps are: 1. Members of the RCA team must first determine exactly what events occurred and in what sequence the events occurred that led to the adverse outcome. Some of the ways this information is gathered are through the interview of staff members and patients or family members, the review of patient charts, and/or the examination of organizational policies and procedures. 2. The second step is for the RCA team to assess what should have happened if the course of events followed the ideal sequence and there was no breakdown in the process or organizational system. 3. The third step of the RCA process is for the team to determine what the actual root cause of the event was. It is often helpful for the team to ask “why” five times to fine-tune the focus to the underlying cause. Some reasons for the event occurring may be direct or obvious factors and other factors may be indirect or cause that contributed to the occurrence of the event. 4. Step four of the RCA process is completed through the creation of statements that links the cause to the effect which then refers back to the incident that necessitated the RCA investigation. This is referred to as a causal statement and it should have three parts to it: the cause of an event, the results, or effect of what happened with a reference back to the original incident. 5. The fifth step is requiring the RCA team to brainstorm some changes that they can recommend to be implemented to prevent the incident from recurring going forward. There are eight categories that most interventions fall under. These are the use of the same equipment by all team members across all units, systems that require a second check or fail- safe, a function that would physically prevent somebody from making a common mistake or oversight, changing the physical makeup of the location where the event occurred, making changes and or improvements to software such as an electronic health record (HER), using visual reminders such as a label or visual cues, making the process or system easier to navigate, educating of staff, and updating or creating new policies and procedures to reflect the expected changes. Part of this step requires the team to identify whether the actions that are recommended are strong and will likely prevent the issue from occurring again; intermediate which targets the root cause of the problem; or weak. A weak action is unlikely to be effective at preventing the incident from reoccurring but may be necessary as an initial measure to raise awareness while strong or intermediate interventions are being put into place. 6. The last step and sixth step are to review the process that the team just completed and document a summary of the event, the causes, and contributing factors, as well as the interventions to be implemented to prevent future occurrences. This summary will be shared with the staff as part of the education process. In order to simplify the information, many RCA teams make use of a flow chart so that staff can easily visualize what specific events took place and the order in which each event occurred that all led up to the adverse event (Institute for Healthcare Improvement, n.d.). A2. Causative and Contributing Factors After receiving a total of 10 mg of Diazepam and 4 mg of Hydromorphone within a 15- minute period, Mr. B became overly sedated and ultimately died as a result. Aspects of the facility’s moderate sedation/analgesia policy were not followed as it required that the medical practitioner show competency in the skill by completing the hospital’s education program before being allowed to perform moderate sedation/analgesia. Dr. T had not completed the required education; therefore, the policy excluded him from performing the procedure. This leaves me to conclude that this policy was disregarded by not only Dr. T but also by the administration as Dr. T was placed on the schedule as the only physician, leaving him with limited options. Another factor that caused Mr. B’s death was related to the lack of sufficient monitoring per the hospital’s moderate sedation/analgesia policy which called for continuous blood pressure, ECG, and pulse oximetry throughout the procedure, as well as post-procedure. Although it is not known if monitoring Mr. B throughout the procedure would have resulted in a different outcome, Nurse J did not place the blood pressure cuff and pulse oximeter on Mr. B until after the procedure was completed and she learned of the incoming patient in acute respiratory distress. No ECG monitor was placed at any time. At this time, Nurse J left Mr. B in the company of his son to care for the incoming patient as well as to discharge the other two less acute patients. Although it is not mentioned as part of the hospital’s policy, there is no mention of Nurse J’s or Dr. T’s attempts to rouse Mr. B to determine his level of sedation. Dr. T stated his goal was placing Mr. B in moderation sedation/analgesia to relax the skeletal muscles and provide pain management for manual manipulation, relocation, and alignment of Mr. B’s injured right hip. A patient under moderate sedation/analgesia should be able to respond purposefully to verbal commands with no more than a light touch needed for arousal. The effect of the medications used for moderation sedation/analgesia should wear off in approximately 15 minutes. We also learned that Mr. B takes oxycodone for chronic back pain, but it does not appear that anyone determined when he last took a dose of Oxycodone. If a dose had been taken within the past 12 hours, it may have contributed to his level of respiratory depression and subsequent death. Although Nurse J has learned that Mr. B takes Oxycodone during the admission assessment, she does not report this to the physician. Additionally, although Dr. T examine Mr. B prior to the procedure, he does not review his chart until after all the medications had been ordered and administered. It is possible that different medications could have been chosen to achieve moderate sedation as there are other acceptable options that are not opiates. If Mr. B had recently taken Oxycodone, the combination of that with the 4 mg of hydromorphone likely contributed to respiratory depression and ultimately led to his death. A patient placed in a moderate sedation/analgesia state should be able to breathe on their own at a rate high enough to maintain adequate oxygenation. Although we do not know Mr. B’s pulse oximetry percentage upon his admission, it was only at 92% when Nurse J first started monitoring just before she left the room. There is no mention of respiratory medical conditions that would cause or contribute to a less than optimal oxygen saturation. Had a pulse oximeter been placed on Mr. B prior to the procedure as the hospital policy requires, both her and Dr. T may have seen the administration of the medications coincide with a decreased oxygen saturation level. If Mr. B’s declining ventilation had been noted sooner, they likely would have been able to lessen or even reverse the sedation to a more optimal level. Another contributing factor to Mr. B’s death is the LPN’s decision to reset the alarm on his monitor that had alerted her to his low O2 level of 85%. This occurred approximately eight minutes after Nurse J left the room. Following the procedure and approximately 23 minutes after Mr. B last received the IVP medications. Although the LPN was unaware of the timeline and medications administered, the LPN should have immediately alerted either Nurse J or Dr. T, as well as provide supplemental O2. At this stage of Mr. B’s declining respiratory status, there still might have been time to reverse the effects of the opioids and save Mr. B’s life. Additional contributing factors are the lack of notification to request additional backup staff for assistance with the incoming acute patient and/or pending discharges. Even when the waiting area became crowded, back up staff were not notified which led to further distraction by Nurse J and Dr. T which decreased the chances that Mr. B could be properly monitored. B. Improvement Plan There are several changes I would implement as part of an improvement plan to prevent a reoccurrence of this sentinel event: • A checklist will be created and utilized pre-procedure to serve as a visual reminder of the steps to be completed and will include a prompt for the physician to review the patient’s medication list and medical history. Any patient that takes opiates even on an as-needed basis will be asked the last date/time they had a dose of the opiate as a recent dose may cause a greater level of sedation and/or respiratory depression than intended. The pre-procedure checklist will also contain a protocol for medications with industry-standard starting doses to be administered to achieve moderate sedation. This list is to include alternative options to be administered in the event of patient allergies or current opioid use. All calculations are to be based on a patient’s weight and are to be verified by a second clinician. If moderate sedation/analgesia is not achieved after the second round of medications, the physician is to consult with anesthesiology. • Create a flowsheet for recording a patient’s vital signs and level of sedation both during and after the procedure. The nurse assisting the physician will document on a flowsheet the patient’s vitals as well as the level of sedation/response to verbal stimuli every three minutes during the procedure. This may help to serve as a visual aid if a patient is slowly deteriorating or becoming more sedated versus just monitoring vital signs. • An addition to the moderate sedation/analgesia policy that states all patients undergoing this procedure must have one-to-one nurse monitoring for 15 minutes following the procedure. This nurse is not to be involved in another task or pulled from the patient being monitored for any reason. During this time, the nurse is to document the patient’s vital signs every five minutes on a flow sheet as well as the patient’s level of responsiveness to verbal stimuli. If at any time, the patient’s level of sedation or vital signs deteriorates or if 10 minutes post- procedure the patient’s level of consciousness has not shown signs of improvement, the physician must be notified and respond to that room for further interventions. • All education sessions of the moderate sedation/analgesia education training should include a mock scenario where team members are presented with several difficult and medically complex scenarios and will be asked to work in pairs to devise a plan for their “response” to this scenario. Each group of two will present their scenario and the steps they would take to the group with opportunities for feedback from the group. • Moving forward, the ER will no longer hire LPNs to work in the ER and establish a minimum set of criteria and experience that all new hires must meet. • Staffing ratio policy will be developed which will clearly define when backup staff needs to be activated. This policy will also take into consideration the acuity level of the patients. The administration will look into best practices utilized by other ERs to determine the best method suited for this ER. • A nursing supervisor position will be created for a 7 am to 7 pm and 7 pm to 7 am position. This person would be the primary person responsible for tracking the acuity level and staff to patient ratio of the ER at any given time and for activating back up staff. The supervisor would be notified of all moderate sedation procedures before they begin and will ensure the pre-procedure checklist is being followed as well as perform random checks of the flow sheet for documentation of vital signs and patient sedation level. This supervisor will periodically check the patient’s response to verbal stimuli and compare them to the documentation on the flow sheet to ensure there is an agreement in the assessment. • The in-house respiratory therapist is to be notified of all moderate sedation/analgesia procedures that will take place before they occur. In the event of a patient’s need for resuscitation, the respiratory therapist will be notified immediately and will aid as needed. • Expand upon the portion of the hospital’s existing moderate sedation/analgesia policy that states no practitioner is to perform this procedure without first successfully completing the hospital’s education module. In a larger ER where more than one physician was scheduled per shift, it might be feasible to leave the language as it is, but in a smaller rural hospital where there are shifts with only one physician scheduled, no physician or nurse should be allowed to work without first completing the hospital’s educational program. By allowing Dr. T to work without having the necessary training to perform a procedure that may be potentially required during the course of his shift, the hospital’s administration also bears responsibility for the tragic event that occurred. This portion of the improvement plan needs to be implemented immediately and there should be no exception to it granted. • Immediately schedule offerings of the above-mentioned education module at various times of the day and/or days of the week in an attempt to accommodate 100% of the ER staff who have yet to complete the required training. These training sessions are to be a full training session for those that have never attended and are the priority personnel that needs to attend. At these training sessions, it would make sense to incorporate the new changes to the policy so that these team members do not have to attend two separate sessions. • Due to the changes being implemented to the moderate sedation/analgesia policy, mandate that all ER physicians and nurses must attend an abbreviated education session that will provide a quick review of the policy with the main focus being on the changes being made to the policy. All ER staff must attend an education session before being allowed to work a shift, so ideally training will be offered at various times of time and on various days of the week to accommodate as many team members as possible and complete the education as quickly as possible. • All staff must undergo annual reeducation of the moderate sedation/analgesia policy. B1. Change Theory Kurt Lewin’s change theory is a way to gain an understanding of the process involved in change. Lewin suggests that in order for change to occur within an organization three phases must occur for the change to have more than a temporary effect. The first stage is the unfreezing stage in which people need to let go of old ideas, attitudes, or practices. He states that in order to help staff with change, they need to understand the reasons that precipitated the need for the change. In this scenario, I think all staff needs to understand the particulars of what occurred during the sentinel event and that blame is not to be assigned to a particular action or one particular person. For instance, with regards to the moderate sedation/analgesia policy change that states no physician or nurse is to be scheduled for a shift until they attend and successfully complete the hospital’s education session may result in staff feeling that the change is a punishment of sorts or that Dr. T made a mistake which resulted in all the staff dealing with this as a consequence. By informing staff members that the change is being implemented to protect them, not punish them and that the prior policy was not being fully enforced by the administration, putting them in a potentially no-win situation. Remind staff members that Dr. T was probably not the first physician to be placed on the ER schedule before completing the education on moderate sedation/analgesia, he was just the unlucky one who ended up in a bad situation who chose to perform the procedure in order to help out a patient in need. I feel that this will help staff in understanding the reasons for the changes in policy and let them know that that administration does not place blame on Dr. T and that administration understands they had previously implemented a policy and then did not protect their own staff when they allowed people to work without being properly educated first. Another thing that can help staff to understand this change is by presenting evidence of similar policies in ERs across the country and that it is now the accepted practice standard (Williams, n.d.). The second stage of Lewin's change theory is called change and is the stage where true changes in behavior will take place. He states that there can be staff frustration during this time, and this can be lessened by providing extra support and resources. One way the administration can provide additional support to lessen staff frustration is by holding multiple education sessions at varying times and days of the week to ensure all team members successfully complete their required moderate sedation/analgesia education as quickly as possible. This would help to minimize staff frustration by accommodating team member’s various schedules, decrease the number of team members who need to miss a shift, while also helping to keep the ER fully staffed to stay open for the community that relies on it (Williams, n.d.). Lewin calls freezing the third stage and is where real change in processes is actively taking place. He states that this stage requires active monitoring and reinforcement of the change to ensure that staff does not begin to revert to the old ways of doing things whenever an issue arises. With regard to the above-mentioned policy change, the administration would want to ensure that the person in charge of the scheduling is not tempted to quietly place a physician or nurse who has not completed the education onto the schedule just because there is an upcoming shift with a hole that the scheduler cannot fill. A roster of who has yet to go through training should be updated and reviewed with the scheduler daily. Random checks of the schedule to ensure no team member has been allowed to work before completing their education requirement can also be done. This will help to ensure a similar situation does not happen again, as well as let the scheduler know that the policy change is being taken seriously (Williams, n.d.). C. General Purpose of FMEA The Failure Modes and Effects Analysis (FEMA) is a tool that helps a team look at a process and determine how that process might fail and, if it does fail, what would the effects be of those failures. It is a proactive method, looking at potential failures before they occur or before the process is put into place compared to an RCA, which is reactive and evaluates an event or failure that already occurred. The tool also helps to assign a score to each potential failure which is then used by a team to prioritize which process or steps of a process they will propose changes to first (Institute for Healthcare Improvement, 2017). C1. Steps of FMEA Process There are five steps in the FMEA process, which are: 1. First, a process must be chosen for evaluation using the FMEA tool. 2. Next, an interdisciplinary team is recruited. This should include people who normally take part in the process. 3. The team must now devise a list of every step that occurs for the process to take place. This list should be written in the actual order that the steps of the process occur. Flowcharts are often utilized to help make the steps easier to visualize. 4. This is where the FMEA table is completed. The first column lists each step in the process. Then for each step of the process, the team completes the columns moving left to right across the page. After the first column containing the steps, the second column is Failure Mode. This is where the team lists things that could go wrong during each step. In the next column titled Failure Causes, the team will list the possible reasons each failure mode might occur. The next column, titled Failure Effects, is a list of what the effect would be if the failure you have listed does occur. The next three columns are where the team will assign a subjective score from 1 to 10 for each Failure Mode, or thing that can go wrong in that step of the process. The first of these columns is the Likelihood of Occurrence where the team determines how likely is it that this particular thing will go wrong. A score of 1 means it is likely not to occur and a score of 10 means it is most likely to occur. The next scoring column is titled the Likelihood of Detection where the team determines if the failure does happen, what are the chances the failure will be discovered. A score of 10 means the failure is likely not to be detected and a score of 1 means it is most likely to be detected. The last scoring column is titled Severity, and this is where the team determines the likelihood that if the failure occurs, what is the likelihood that severe harm will occur. A score of 10 means that the failure is most likely to cause severe harm and a score of 1 means it the failure is least likely to cause severe harm. This is not a score of the severity potentially caused but the likelihood of severe harm. The next column is the Risk Profile Number (RPN) and this is simply a calculation where the score from 1 to 10 that was assigned in the previous three columns are multiplied together (likelihood of occurrence x likelihood of detection x severity). The results will be anywhere from 1, which is the lowest possible score to 1,000, which is the highest possible score. The team can determine the RPN for the entire process by taking the RPN calculated for each possible failure and add them together. The last column is where the team will list things that can be done to lessen the chances of that failure or to decrease the likelihood of severe harm. The failure modes that have the highest scoring RPNs would be addressed first. 5. The final step of the FMEA process is to use the RPN scores to prioritize ways in which improvements can be made. Failure modes that were calculated with a high RPN are likely where improvements will need to be made as compared to those with low RPNs. Some actions may be aimed at reducing the possibility of harm or to increase the likelihood the failure will be detected if it will occur (Institute for Healthcare Improvement, 2017). C2. FMEA Table See attached table D. Intervention Testing To evaluate if the improvement plan would be effective, we would need to test on a small scale whether or not this process would work using the Plan-Do-Study-Act (PDSA) cycle. The portion of the improvement plan I would like to focus on is the use of the checklist for the physicians to utilize as a visual guide to ensure medical history and list of medications is reviewed. The checklist also prompts the physician to determine if a patient is on opioids, what time the last dose of an opioid was taken. The checklist also contains a guideline of medications to use with alternatives for patient allergies and if a patient is already on opiates. They are to calculate the dose and have the RN verify. Because this is a smaller rural hospital, a moderate sedation/analgesia procedure is likely not performed often. Because of that, the team may have to wait. I would ensure there are checklists available (Plan) and all the nurses are aware that in the event a need for a moderate sedation/analgesia procedure, I would like them to first wait to see if the MD retrieves the checklist and, if not, they are to hand one to the MD under the direction of the administration. Executing (Do) the plan likely will require waiting until the opportunity does present itself and the test will likely be with only one patient. I would also advise nursing that they may speak up to remind the MD of any part of the process but that I am requesting they make a note of it for informational purposes for the team. The nurse will be asked to send a copy of the checklist to the FMEA team and include any notes of where the physician needed to be prompted. The FMEA team would then review (Study) what actually occurred to determine if the physician initiated the checklist on their own or had to be handed one and whether or not they just abided by portions of the checklist they found to be useful to them or if they utilized the entire list. Depending on the amount of prompting the physician required would depend on the next step (Act) and whether or not the team moves forward with making changes to the checklist or rolls it out as is. If there is significant push back from physicians, they may need to be directly involved in this process in order to have them invested in the process. E. Demonstrate Leadership A professional nurse can demonstrate leadership in promoting quality care by continually presenting themselves and their work professionally. If a professional nurse is not seen as a role model whom others want to emulate, I believe the quality of that nurse’s care can be top-notch, but it will not even be seen or recognized by others. The nurse must first display attributes others want to emulate such as professionalism, respect, positive attitude, compassion, and a mentor just to name a few. But to promote quality care, it must go beyond this. For example, if a professional nurse is rounding with the wound team, it can be helpful for that nurse to get involved and get their hands dirty so to speak. By being the nurse who applies the dressing in a perfectly sterile technique, it sets the bar for everyone else. It is ok that only a few nurses witness this dressing change as word will likely travel quickly about the skill and quality of your work. When working in a leadership position, I always tried to maintain the stance that I would never ask a nurse or aide who worked for me to do something I wasn’t willing to do myself from time to time. Sometimes showing how something is done right, even when you do not think you have an audience, is the best way to raise the bar and the quality of care being provided to your patients. A professional nurse can demonstrate leadership in improving patient outcomes by continually seeking out knowledge of what is current in the world of nursing, healthcare, and your practice environment. Whether this is as simple as reading nursing journals and sharing the information with your staff about a new wound care treatment or through expanding your expertise in the field with a certification in your specialty area, a professional nurse interested in improving patient outcomes should always be expanding their knowledge and sharing that knowledge with others. A good nursing leader will not be satisfied with the expansion of their knowledge, but also encourage their staff to do the same. I was a staff nurse for several years when my Director of Nursing approached me about filling in as a unit manager. That same nurse hired me a few years later to be her Assistant Director of Nursing and it all started with her words of encouragement and telling me she saw something in me when she asked me to fill in on occasion as a unit manager. That one conversation changed my nursing career forever and I would like to think that patient outcomes have been influenced and positively influenced by that encouragement. Until that point, I was content with the status quo and never considered much beyond mandatory CEUs to renew my nursing license. A professional nurse can demonstrate leadership in the influence of quality improvement activities by never settling and letting the environment be a status quo. An example might be if you oversee a nursing unit who has been tracking the patient fall rate shows a 10% reduction in falls from one month to the next. Celebrate the hard word but do not settle there. Perhaps there is room for another 10% reduction the following month. Or if fall numbers are as low as possible, what patient outcome can be improved next? Obviously as a nurse leader, sometimes there are certain areas you or administration has determined need to be addressed first, but after those areas are addressed, I think it is beneficial for a good nurse leader to speak to their staff and gather input on what outcomes they would like to see improved. Perhaps they wish they could have more patients attend the dining room for lunch meals? Perhaps they want to have the best satisfaction scores in the organization? The more personally invested your staff is to improve the outcomes of their patients, the better your chance at success. E1. Involving Professional Nurse in RCA and FMEA Processes By involving the professional nurse in the RCA and FMEA processes, the interdisciplinary team gains a unique and likely more accurate perspective of how a process plays out on the unit. More importantly, a professional nurse who demonstrates good leadership skills takes the time to listen to her staff of nurses and aides and hears where or how the process can work better. A nurse who demonstrates good leadership skills also hears the concerns of the patients and/or the families on the unit and brings those forward when serving as a member of the RCA or FMEA team. By concerns I do not just mean the direct complaints or issues on the floor, a good nurse who is a good leader knows to look beyond the concerns and has perhaps already determined what is at the root of their concerns. An example in my career that comes to mind is complaints by the staff that they never could find a working or all the pieces of a patient alarm. Meanwhile, our quality numbers were showing a higher than normal fall rate, but I had noted our recent admissions were frailer, less conditioned, and more likely to fall than the admissions we had received six months before. The quality improvement and fall teams wanted answers and we had scheduled a meeting to look at a root cause analysis and the process of assessing people on admission. One nurse had spoken up with the theory that the nurses on the unit “weren’t assessing people right.” Prior to the meeting, I took a look at a handful of fall assessments completed recently and found no issues. So, what was the issue? I remembered the complaints by the aides that they needed a new bed and chair alarms because ours were always broken. I then sat down with the equipment manager to figure out what the process was for getting new equipment. After I was told it was not in the budget, out of curiosity, I asked what the process was for maintaining the alarms and how did the aides go about getting an alarm from him? It turns out there was no process. There was a big plastic bucket with various alarm pieces and aides were to just leave to try to piece them together. They borrowed working batteries from one to put in another and put together a functioning alarm to the best of their ability. It turned out the equipment manager thought managing the equipment was just having aides go to his office to get the alarms on their own. By the time the meeting rolled around, with the help of all staff, we had done a massive reconnaissance to locate alarm parts. With all brand-new batteries, we had very few non-working alarms. We inventoried them, assigned numbers to each component, and instituted a new sign-out system that the equipment manager went around and audited monthly. Turns out, our admissions were becoming frailer and at risk for falls, but it was a simple matter of listening to what the issues were that solved this problem! References Institute for Healthcare Improvement. (2017). QI essentials toolkit: Failure modes and effects analysis (FMEA). Retrieved from Institute for Healthcare Improvement. (n.d.). Patient safety 104: Root cause and systems analysis. Retrieved from https://srm-- id=0BE0cLYai . Williams, D. (n.d.). Quality improvement 201: Planning for spread: From local improvements to system-side change. Retrieved from 9abd-d90849f183d4/ea07c796-abd8-b6c793/lessonDetail/2adf747a- 862f-4862-ab0c-f05b67/page/1