ORGANIZATIONAL SYSTEMS & QUALITY LEADERSHIP

Competencies:
734.3.1: Principles of Leadership
 – The graduate applies principles of leadership to promote high-quality healthcare in a variety of settings through the application of sound leadership principles.
734.3.2: Interdisciplinary Collaboration – The graduate applies theoretical principles necessary for effective participation in an interdisciplinary team.
734.3.3: Quality and Patient Safety – The graduate applies quality improvement processes intended to achieve optimal healthcare outcomes, contributing to and supporting a culture of safety.


Task 2: RCA and FMEA

Introduction:

Healthcare organizations accredited by the Joint Commission are required to conduct a root cause analysis (RCA) in response to any sentinel event, such as the one described in the scenario attached below. Once the cause is identified and a plan of action established, it is useful to conduct a failure mode and effects analysis (FMEA) to reduce the likelihood that a process would fail. As a member of the healthcare team in the hospital described in this scenario, you have been selected as a member of the team investigating the incident.

Scenario:

You can find the scenario attached below in the attachment section.

Requirements:

Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. Use the Turnitin Originality Report available in Taskstream as a guide for this measure of originality.

You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.



A.  Explain the general purpose of conducting a root cause analysis (RCA).

1.  Explain each of the six steps used to conduct an RCA, as defined by IHI.

2.  Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome.
 

B.  Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome.

1.  Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan.
 

C.  Explain the general purpose of the failure mode and effects analysis (FMEA) process.

1.  Describe the steps of the FMEA process as defined by IHI.

2.  Complete the attached FMEA table by appropriately applying the scales of severity, occurrence, and detection to the process improvement plan proposed in part B.
 

Note: You are not expected to carry out the full FMEA.
 

D.  Explain how you would test the interventions from the process improvement plan from part B to improve care.
 

E.  Explain how a professional nurse can competently demonstrate leadership in each of the following areas:

•  promoting quality care

•  improving patient outcomes

•  influencing quality improvement activities

1.  Discuss how the involvement of the professional nurse in the RCA and FMEA processes demonstrates leadership qualities.
 

F.  Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.
  G.  Demonstrate professional communication in the content and presentation of your submission.

  Not Evident Approaching Competence Competent
A. Root Cause Analysis An explanation of the general purpose of conducting an RCA is not provided. The explanation does not accurately describe the general purpose for conducting an RCA. The explanation accurately describes the general purpose for conducting an RCA.
A1. RCA Steps An explanation of 6 RCA steps is not provided. The explanation does not accurately identify or does not logically describe one or more of the 6 steps used to conduct an RCA, as defined by IHI. The explanation accurately identifies and logically describes each of the 6 steps used to conduct an RCA, as defined by IHI.
A2. Causative and Contributing factors An application of the RCA process to the scenario is not provided. The application of the RCA process to the scenario does not accurately describe causative or contributing factors that led to the sentinel event outcome, or the application does not accurately differentiate between causative and contributing factors. The application of the RCA process to the scenario accurately describes the causative and contributing factors that led to the sentinel event outcome.
B. Improvement Plan A proposed process improvement plan is not provided. The proposal does not outline a logical process improvement plan, or the proposal does not logically discuss how the proposed plan will decrease the likelihood of a reoccurrence of the scenario outcome. The proposal outlines a logical process improvement plan and logically discusses how the proposed plan will decrease the likelihood of a reoccurrence of the scenario outcome.
B1. Change Theory A discussion of the application of Lewin’s change theory is not provided. The discussion does not logically describe how Lewin’s change theory could be applied to the proposed improvement plan, or the discussion does not describe each phase of the theory. The discussion logically describes how each phase of Lewin’s change theory could be applied to the proposed improvement plan.
C. General Purpose of FMEA An explanation of the general purpose of the FMEA process is not provided. The explanation does not accurately describe a general purpose of the FMEA process, or the explanation does not logically discuss why the FMEA process would be used. The explanation accurately describes a general purpose of the FMEA process and logically discusses why the FMEA process would be used.
C1. Steps of FMEA process A description of the steps is not provided. The description of the steps of the FMEA process does not accurately define each of the steps. The description accurately defines each of the steps of the FMEA process.
C2. FMEA table A completed FMEA table is not provided. The FMEA table is incomplete,  does not identify appropriate failure modes related to the improvement plan proposed in prompt B, or does not accurately apply the scales of severity, occurrence, and detection in evaluating the identified failure modes. The completed FMEA table appropriately identifies failure modes related to the improvement plan proposed in part B and demonstrates accurate application of the scales of severity, occurrence, and detection in evaluating the identified failure modes.
D. Intervention Testing An explanation of intervention testing is not provided. The explanation does not describe steps of an appropriate testing procedure or practice that would be used by the candidate to test interventions from the process improvement plan in part B, or the explanation does not logically describe how the intervention testing procedures or practices would improve care. The explanation describes steps of the testing procedures or practices that the candidate would use that are appropriate for testing the interventions from the process improvement plan in part B. The explanation logically describes how the intervention testing procedures or practices would improve care.
E. Demonstrate Leadership An explanation of how a professional nurse demonstrates leadership is not provided. The explanation does not logically describe how a professional nurse competently demonstrates leadership in one or more of the given areas. The explanation logically describes how a professional nurse competently demonstrates leadership in each of the given areas.
E1. Involving Professional Nurse in RCA and FMEA Processes A discussion of involvement in the RCA and FMEA processes is not provided. The discussion does not logically describe how the involvement of the professional nurse in either the RCA process or the FMEA process demonstrates leadership qualities. The discussion logically describes how the involvement of the professional nurse in both the RCA and FMEA processes demonstrates leadership qualities.
F. Sources The submission does not include both in-text citations and a reference list for sources that are quoted, paraphrased, or summarized. The submission includes in-text citations for sources that are quoted, paraphrased, or summarized and a reference list; however, the citations or reference list is incomplete or inaccurate. The submission includes in-text citations for sources that are properly quoted, paraphrased, or summarized and a reference list that accurately identifies the author, date, title, and source location as available.
G. Professional Communication Content is unstructured, is disjointed, or contains pervasive errors in mechanics, usage, or grammar. Vocabulary or tone is unprofessional or distracts from the topic. Content is poorly organized, is difficult to follow, or contains errors in mechanics, usage, or grammar that cause confusion. Terminology is misused or ineffective. Content reflects attention to detail, is organized, and focuses on the main ideas as prescribed in the task or chosen by the candidate. Terminology is pertinent, is used correctly, and effectively conveys the intended meaning. Mechanics, usage, and grammar promote accurate interpretation and understanding.

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