C489 Task 3
Organizational Systems and Quality Leadership
Systemic Change in Organizations
WGU
I shall compare the US healthcare system to the German healthcare system.
Germans enjoy free access to medically essential public healthcare. Healthcare is funded by Social Security contributions. The state or private health insurance mandate. Include vaccines, medications, and dental exams. Private health insurance is not authorized for salaried workers in Germany. If you qualify for private insurance, you can select between the two, but not both. (German Insurance: 2019)
In the US, free public health care is available to those who meet certain qualifications. Medicaid is a government-funded insurance that helps many whose household income falls below a specific level. In Germany, if an individual is employed, the family is covered as long as their income is below a certain amount. It’s a win-win! (Healthcare in 2015) Medicare covers people over 65 or with impairments. Medicare is a publicly sponsored healthcare system in the US. For children under the age of 26, there are government programs such as the Children’s Health Insurance Program (CHIP) that provide coverage through Medicaid and other programs. The state and federal governments fund them. (2019)
Unemployed Americans may not be eligible for government help. Unlike in the US, unemployed Germans may receive temporary coverage until reemployed or otherwise directed.
In the US, at age 65, you are eligible for Medicare, which covers some but not all of your medical expenses. You can purchase private Medigap coverage to bridge the gap. If you can’t afford it and meet certain income requirements, you may be eligible for Medicaid.
Germany has a contributing, noncontributory, and social welfare system. The contributory plan protects its members. The noncontributory social compensation program helps persons who are not qualified for the other two programs. (Healthcare in 2015)
Medication costs are high in both the US and Germany without health insurance. In many circumstances, the US and Germany have cost-effective drug options. Many diseases have affordable treatments, but many illnesses have expensive medications, even with good coverage. In the US, many people utilize generic or cheaper alternatives, or avoid the drug altogether. In Germany, the more expensive medications must prove they are genuinely superior than the older counterpart, and you are responsible for the expense if you want to use the more expensive treatment. (Khazan)
In the US, specialists are referred based on the plan’s criteria. Others require a recommendation. In Germany, social plans require a PCP referral, whereas private insurers allow participants to choose any physician they want. (Healthcare in 2015)
The Affordable Care Act states that pre-existing conditions cannot be denied coverage in the US. Pre-existing conditions are not covered in Germany. Elective treatments and accommodations can be denied coverage or charged extra premiums.
In Germany, this means higher taxes to pay social sickness funds. They are instructed to care for one another, but many contend that extra taxes will burden already taxed families. In the US, persons who opt not to purchase health insurance pay a penalty. Non-eligible workers may be unable to afford health insurance.
(ASPA), H. S. (2017, January 31). www.hhs.gov. The ACA’s website has more information about pre-existing conditions, including a list of ACA members. CHIP. (26 July 2019) https://www.medicaid.gov/chip/index.html German Insurance: Prices and Coverage 5 July 2019. Health insurance in Germany is a must for all expats, according to www.internations.org. German healthcare. 6 May 2015 https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0078017/ Okhazan (2014). Why German Medicine is Cheaper Atlantic.
Organizational Systems and Quality Leadership
Task 2: RCA AND FMEA
Explain the general purpose of conducting a root cause analysis (RCA).
A root cause analysis (RCA) is a process for classifying the cause of a problem, and then a good way to approach and respond to the problem. The goal is to examine what happened, how the issue happened, and why it happened so that actions can be put into place to prevent a reoccurrence from happening (Institute for Healthcare Improvement).
Explain each of the six steps used to conduct an RCA, as defined by IHI.
Most often and RCA team involves four to six individuals from a mix of different professions. Each person should have fundamental knowledge of the problems and procedure involved in the accident. There is a total of six steps. The first step is to identify what happened. The team needs to explain what happened by organizing the information to clarify exactly what took place. The second step is to determine what should have happened. The team can create a chart to better understand what should have happened in an ideal situation. Number three is to determine causes (“Ask why five times”). This is how the team determines the factors that lead to the event. They look at the direct causes and the contributory factors as to why the incident happened. The fourth step is to develop causal statements. This is how they explain how the contributory factors lead to the bad outcomes. Step number five is to generate a list of recommended steps to prevent the recurrence of the event, which are changes that the team thinks will aid in preventing the error from happening again. The final sixth step is, write a summary and share it. This can help to engage people to aid in the steps of improvement (Institute for Healthcare Improvement).
Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome.
The first step is to identify what happened: Mr. B is a 67-year-old male who is 175lbs with a past medical history of, chronic back pain which he was taking oxycodone for, impaired glucose tolerance, prostate cancer, high cholesterol, and high triglycerides. He was brought to the Emergency department (ED) by his son and neighbor complaining of pain in the left leg and left hip. He states he lost balance and tripped over the dog causing him to fall. When he had arrived at the ED, his blood pressure, heart rate and temp were all within normal limits, and his respirations were noted to be elevated at 32 which could be from the severe pain he was experiencing, which he rated 10/10. He was noted to have shortening of the left leg, edema, ecchymosis, and limited range of motion. There were two nurses (an LPN and an RN), an ER doctor, one secretary, and hospital respiratory therapist on staff at this rural hospital. Mr. B was the third patient in the ER at the time of arrival. The doctor evaluated Mr. B and ordered the RN to give 5mg of diazepam IV push, when that did not have an effect after 5 minutes the doctor then ordered the RN to give Hydromorphone 2mg IV push which was given 10 minutes later. The doctor was still not happy with the results after 5 minutes so, he then ordered to give another 2mg of Hydromorphone and an additional 5mg of diazepam both IV push. The sedation goal of the doctor was finally achieved, and he performed a reduction of the left hip. The patient had tolerated the procedure and he was still sedated, without any supplemental oxygen placed. The ED was then notified of a patient on the way in for acute respiratory distress, so the nurse put the patient on an automatic blood pressure and pulse oximeter reading every 5 minutes and she left the room leaving the son to sit with the patient. Five minutes after the procedure had ended the patients blood pressure had decreased to 110/62 and his oxygen saturation decreased to 92%, remaining without supplemental oxygen, and without ECG and respiration monitoring. While the RN and LPN were occupied with the new arrival, Mr. B’s oxygen monitor was alarming to indicate his oxygen had dropped to 85%. Then Mr. B’s son came out to alarm the nurse that the monitor was ringing again, she finally entered the room to find his blood pressure at 58/30 and oxygen level at 79%, Mr. B had no signs of breathing and there was no palpable pulse. The nurse called a STAT code and resuscitative efforts were started, he was intubated, defibrillated, given reversal agents, given IV fluids, and given vasopressors. This lasted 30 minutes, the ECG returned to normal sinus rhythm, blood pressure was 110/70. Mr. B was fully dependent on the ventilator, his pupils were fixed and dilated, and he was not responding to stimuli. Mr. B was then transferred to a different hospital for care upon the families wishes. Seven days after this ER visit, Mr. B was given a “brain dead” diagnosis, the family decided to remove life support and Mr. B had passed away.
The second step is to identify what should have happened. The doctor and nurse needed to be trained on the conscious sedation protocols in place, as well as known the proper dose and proper drugs to be used in this situation. If the nurse knew the drug dosing, she should have questioned the medication that was ordered to give to this patient. The nurse should of abided by the hospital protocol and placed the patient on continuous blood pressure, ECG, and pulse oximeter reading throughout the procedure and until the patient meets the criteria for discharge which was, being fully awake, vital signs being stable, no nausea or vomiting, and able to void. When Mr. B’s oxygen saturation was dropping the LPN should have notified the RN, instead she just silenced the alarm from going off which defeats the purpose of the alarm. Finally, the ER should have called for additional nurses and staff to Help with the current patients to prevent any accidents from happening.
The third step is to determine the causes of the event. The direct cause of death would be the irreversible brain damage due to lack of oxygen for a prolonged period of time. The the contributory factors to the patient’s death would be the lack of staffing, the doctor over sedating the patient for the procedure, not adhering to the protocol for proper conscious sedation monitoring, and ignoring the patients alarm for low oxygen saturation.
Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome.
The first thing that I would propose as an improvement plan to prevent a reoccurrence of this scenario is to conduct a mandatory training for the physicians, RNs, LPNs, and Respiratory Therapist regarding the conscious sedation protocol, that way everyone has the information needed including how to monitor, and what vitals to be monitoring. Then the only ones available to care for a patient that requires conscious sedation would be the ones who have successfully completed the training. I would propose to upper management that patients who have undergone conscious sedation require mandatory one on one monitoring until the criteria is met.
Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan.
The Lewin’s change theory has three steps; including unfreeze=change=refreeze. Individuals are not open to change, they get comfortable with their routine and tend to resist any change. However, revealing that there is a problem in the system requires the proper steps to change and make things more effective. In this scenario the staff need to be aware of the issues that have taken place, and then convinced of the benefits of change to them as well as the patient. Hosting a meeting to discuss the event and what took place and what needs to take place to improve care and prevent this from reoccurring. Change is not easy for anyone but taking the proper approach to initiate the change, provide support for the change, and then monitor to make sure the change is being used will make it easy for everyone in this process (Mind Tools, 2019).
Explain the general purpose of the failure mode and effects analysis (FMEA) process.
The Failure Mode and Effects Analysis (FMEA) is a step by step approach to identify possible problems before they occur. It is used to take action in reducing and eliminating failures. They also document the current knowledge about the risk of failures to continue improvements (Institute for Healthcare Improvement, 2020).
Describe the steps of the FMEA process as defined by IHI.
The first step of the FMEA process identified by the IHI is, define the scope and topic of the FMEA. The second step is to assemble a multi-disciplinary team of involved professionals. The third step is charting the steps of the process. The fourth step is hazard analysis which the team analysis completes the chart showing all the possible ways the process could fail, which includes the likelihood and severity. The fifth and final step is uses risk profile numbers (RPNs) to plan improvement, which identifies ways to keep the high-risk plans from failing (Institute for Healthcare Improvement, 2020).
Complete the attached FMEA table by appropriately applying the scales of severity, occurrence, and detection to the process improvement plan proposed in part B.
List 4 steps in your Improvement Plan Process
List 1 Failure Mode per step
Likelihood of Occurrence (1–10)
Likelihood of Detection (1–10)
Severity
(1–10)
Risk Priority Number
(RPN)
1. All physicians, RNs, LPNs, and Respiratory therapist do mandatory conscious sedation training
The protocol will not be followed as directed
6
7
6
252
2. Utilizing continuous O2 monitoring during and after the conscious sedation procedure until criteria is met
staff may take off monitor prior to criteria being met
7
6
9
378
3. Monitoring Blood pressure, and pulse before, during and after procedure
The patient’s vitals will fall or rise into abnormal values
6
4
8
192
4. Nurses and Doctors need to have mandatory training on medication to give for conscious sedation procedures
They will not abide by the medication administration rules in place causing patients to be at risk
8
6
10
480
Total RPN (sum of all RPN’s): 1,302
Explain how you would test the interventions from the process improvement plan from part B to improve care.
To test the interventions from the process improvement plan, there would need to be intense monitoring taking place to confirm that the staff are complying. There would need to be someone conducting a chart review of patients who underwent conscious sedation to show and prove that the staff is using the new policies and procedures. Analyzing these patients’ vital signs to measure improvement and compliance as well. Supervisors could do random checks to make sure staff are abiding by the protocols.
Explain how a professional nurse can competently demonstrate leadership in each of the following areas:
• promoting quality care – Professional nurses can demonstrate leadership in promoting quality of care by advocating for the patient. Some of the patients are in their most vulnerable state, and if the nurse is listening to their concerns and speaking up for them when needed if the patient is at a compromised state then this is giving quality care to that patient.
• improving patient outcomes- Professional nurses can demonstrate leadership in improving patient outcomes by adhering to the set protocols to ensure patient safety. The nurse should always have the patient’s best interest at heart so providing compassionate, caring, safe care should improve patient outcomes, so they feel they are taken care of in the best way possible.
• influencing quality improvement activities- Professional nurses can demonstrate leadership in influencing quality improvement activities by constantly educating yourself and evolving with the standards of care. As a nurse leader you will have the quality indicators examined regularly and be ready to change as needed.
Discuss how the involvement of the professional nurse in the RCA and FMEA processes demonstrates leadership qualities.
The professional nurse should be involved in the RCA and FEMA processes because they are a part of the team. Nurses should implement and evaluate plans and processes continuously. As a nurse you are constantly using your critical thinking skills to best Help the patient and you are an advocator for the patients. So, if you are involved in these two processes most likely patient outcomes will be improved because nurses are on the forefront of patient care.
References
Institute for Healthcare Improvement. (2020). Failure Modes and Effects Analysis( FMEA) Tool. Retrieved
from http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx
Institute for Healthcare Improvement. Patient Safety 104: Root Cause and Systems Analysis. Retrieved
on February 4, 2020 from app.ihi.org/LMS/Content/f99b4ea2-aeea-432d-a3573ca88b6ae886/Upload/PS%20104%20SummaryFINAL.pdf
Mind Tools. Lewin’s Change Management Model – Understanding the Three Stages of Change
(October 5, 2019) Retrieved from https://www.mindtools.com/pages/article/newPPM_94.htm
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Systemic Change in Organizations
RCA AND FMEA
WGU
Explain the aim of a root cause analysis (RCA).
One strategy to approach and solve a problem is to employ root cause analysis (RCA). The purpose is to figure out what happened, how it happened, and why it happened so that preventative measures can be taken (Institute for Healthcare Improvement).
Explain the six steps of an RCA as outlined by IHI.
A typical RCA team consists of four to six people from diverse backgrounds. Everyone engaged in the accident should have a basic understanding of the issues. There are six steps. Find out what happened first. The team must organize the facts to describe what happened. After that, figure out what should have happened. The team can make a chart to visualize what should have happened. 3. Determine causes (“Ask why five times”). This is how the team finds the cause. They investigate into the incident’s immediate and indirect causes. Step 4: Create causal assertions. This is how they explain the contributing factors. To prevent recurrence of the event, the team recommends adjustments that they believe will help prevent the error from occurring again. The sixth stage is to write and present a summary. This can Help engage people in the improvement process (Institute for Healthcare Improvement).
Describe the causal and contributory variables that lead to the sentinel event outcome using the RCA procedure.
Find out what happened first: This 67-year-old male has a history of persistent back pain, impaired glucose tolerance, prostate cancer, excessive cholesterol, and high triglycerides. His son and neighbor brought him to the ED with complaints of leg and hip pain. He says he lost his footing and stumbled over the dog, falling. Slightly higher respirations (32), possibly due to his significant pain (10/10), when he came at the ED. His left leg was shortening, edema, ecchymosis, and he had limited range of motion. This rural hospital had two nurses (an LPN and an RN), an ER doctor, a secretary, and a hospital respiratory therapist. Mr. B arrived as the third patient in the ER. The doctor reviewed Mr. B and ordered the RN to give him 5mg diazepam IV push, and when that didn’t work after 5 minutes, the doctor ordered 2mg Hydromorphone IV push. After 5 minutes, the doctor ordered 2mg Hydromorphone and 5mg Diazepam IV pushes because the outcomes were still unsatisfactory. The doctor achieved his sedative aim and reduced the left hip. The patient had tolerated the procedure well and was remained sedated with no oxygen. The nurse put the patient on an automatic blood pressure and pulse oximeter reading every 5 minutes and left the room leaving the son to sit with the patient. After the surgery, the patient’s blood pressure dropped to 110/62 and his oxygen saturation dropped to 92%, leaving him without supplemental oxygen, ECG, or respiratory monitoring. While the RN and LPN were busy with the new patient, Mr. B’s oxygen level had plummeted to 85%. On entering the room, she found Mr. B’s blood pressure at 58/30, his oxygen level at 79%, no evidence of respiration and no detectable pulse. He was intubated, defibrillated, given reversal medications, IV fluids, and vasopressors. This lasted 30 minutes, and the ECG reverted to normal sinus rhythm. Mr. B was on a ventilator, his pupils were fixed and dilated, and he was unresponsive. Mr. B was then sent to a different hospital at the families request. Mr. B was diagnosed as “brain dead” seven days later, and his family decided to terminate life support.
To indicate what should have happened next. The doctor and nurse needed to know the right dose and medications to utilize in this case. If the nurse knew the drug dosage, she should have questioned the patient’s medication. After the procedure, the nurse should have continued to monitor the patient’s blood pressure, ECG, and pulse oximeter until they met the requirements for discharge, which included being awake, stable vital signs and able to void. Instead of notifying the RN when Mr. B’s oxygen saturation dropped, the LPN just muted the alarm, defeating its purpose. Finally, the ER should have requested more nurses and staff to help with the current patients to avoid any mishaps.
The next stage is to identify the causes. The direct cause of death is irreparable brain damage from prolonged oxygen deprivation. The patient died due to a shortage of staffing, the doctor oversedating the patient for the procedure, not following protocol for conscious sedation monitoring, and ignoring the patients low oxygen saturation alarm.
Propose a process improvement plan to reduce the likelihood of the incident occurring again.
First, I would suggest that all physicians, RNs, LPNs, and Respiratory Therapists receive required training on the conscious sedation procedure, including how to monitor and what vitals to monitor. Only those who have successfully completed the training would be able to care for a patient requiring conscious sedation. I would suggest to senior management that conscious sedation patients be monitored one on one until the criteria is met.
Discuss how Lewin’s human side of change theory could be applied to the proposed improvement plan.
Unfreeze=change=refreeze is the Lewin’s change hypothesis. People are not open to change, they get used to their routine and fight any change. However, uncovering a systemic flaw necessitates corrective action to improve efficiency. In this case, the personnel must be made aware of the concerns and convinced of the benefits of change for all parties. Organizing a meeting to review what happened and what needs to be done to improve care and prevent reoccurrence. Change is difficult for everyone, but taking the necessary steps to initiate, support, and monitor the change will make it easier for everyone involved (Mind Tools, 2019).
Explain the purpose of FMEA.
The Failure Mode and Effects Analysis (FMEA) is a systematic method for predicting potential problems. It is used to reduce and eliminate failures. They also document current understanding about failures to improve (Institute for Healthcare Improvement, 2020).
Describe the IHI’s FMEA procedure steps.
The IHI recommends defining the scope and topic of the FMEA as the first stage. The second step is to put together a multi-disciplinary team of experts. The next stage is to chart the process. The team completes the chart demonstrating all the different ways the process could fail, including the likelihood and severity. The fifth and final step employs risk profile numbers (RPNs) to plan improvement (Institute for Healthcare Improvement, 2020).
Complete the FMEA table by applying the severity, occurrence, and detection scales to the process improvement plan in section B.
Describe your Improvement Plan Process.
Step 2: List 1 Failure Mode
Probability (1–10)
Detectability (1–10)
Severity
(1–10)
Priority of Risk
(RPN)
Training for all physicians, nurses, LPNs, and respiratory therapists is mandatory.
The protocol is not being followed.
6
7
6
252
2. Constant O2 monitoring during and after conscious sedation until criteria are met
Staff may leave monitor before criteria is met.
7
6
9
378
(3). Pre, during, and post-procedure monitoring
The patient’s vital signs will fluctuate.
6
4
8
192
4. Conscious sedation medication training for nurses and doctors should be essential.
They will not follow pharmaceutical administration standards, putting patients at risk.
8
6
10
480
Total RPN: 1,302
Explain how you would test the process improvement initiatives from part B to improve care.
To test the process improvement plan’s interventions, intensive monitoring is required to ensure staff compliance. To demonstrate compliance with the new policies and procedures, a chart review of patients who had conscious sedation is required. Taking note of their vital signs to assess improvement and compliance. Supervisors could conduct random inspections to ensure personnel follow protocol.
Explain how a professional nurse may effectively lead in the following areas:
• encouraging excellent care – Professional nurses may advocate for patients and promote quality treatment. If the nurse is listening to the patient’s concerns and speaking up for them when necessary, then the nurse is providing quality care.
The professional nurse can lead in improving patient outcomes by following established guidelines to guarantee patient safety. Providing compassionate, caring, safe treatment should enhance patient outcomes and make them feel taken care of in the greatest way possible.
• influencing quality improvement activities- Professional nurses can demonstrate leadership in influencing quality improvement activities by constantly educating yourself and evolving with the standards of care. As a nurse leader, you will periodically review quality indicators and make changes as appropriate.
Explain how the professional nurse’s involvement in the RCA and FMEA processes indicates leadership.
As a team member, the professional nurse should be participating in the RCA and FEMA procedures. Nurses should implement and evaluate plans and processes continuously. As a nurse you are constantly using your critical thinking skills to best Help the patient and you are an advocator for the patients. So, if you are involved in these two processes most likely patient outcomes will be improved because nurses are on the forefront of patient care.
References
Institute for Healthcare Improvement. (2020). Failure Modes and Effects Analysis( FMEA) Tool. Retrieved
from http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx
Institute for Healthcare Improvement. Patient Safety 104: Root Cause and Systems Analysis. Retrieved
on February 4, 2020 from app.ihi.org/LMS/Content/f99b4ea2-aeea-432d-a3573ca88b6ae886/Upload/PS%20104%20SummaryFINAL.pdf
Mind Tools. Lewin’s Change Management Model – Understanding the Three Stages of Change
(October 5, 2019) Retrieved from https://www.mindtools.com/pages/article/newPPM_94.htm
