Organizational Systems & Quality Leadership Task 2
Healthcare organizations are required by their accrediting agencies to demonstrate methods of investigating sentinel events. Root cause analysis (RCA) is a systematic approach to investigating sentinel events used by institutions accredited by the Joint Commission. Once this process helps to identify the causes of the event and a plan to correct the causes, the failure mode and effects analysis (FMEA) is used to identify and decrease the ways the plan could fail. The task analyses these processes and the professional nurse’s role as a leader in the promotion of quality care.
A. Root Cause Analysis The RCA process is used when errors occur to identify potential prevention strategies. The …show more content…
The policy changes will outline the use of a checklist that includes a time out component to guide the staff through the process. The checklist will address: verify consent is obtained, all equipment available, IV is patent, reversal agents at bedside, respiratory therapist present, pre-procedure vital signs and assessment criteria. The time out component requires all staff to stop, agree upon and record: time, proper identification of the patient, the intended procedure, and laterality if applicable. Vital signs are obtained every five minutes during and after the procedure until the patient meets defined criteria (Huber & Ogrinc, …show more content…
Incorporating a change model to help guide the management process can help make the change successful. Kurt Lewin’s change model will provide the direction for this scenarios process improvement plan. This model proposes that change within an organization will occur in these stages: unfreezing, change, and refreezing. The first stage of unfreezing involves changing the current method of proceeding into a procedure without adequate communication and preparation to a process of forethought and safety. The staff will be included in the preparation of the new process, the education on its use, why the change is necessary and what it will accomplish. Research on quality improvements with the use of checklist and time-out will be shared with the staff. The second step involves the process of the change. This will be the most difficult stage for the staff and they will require a lot of support with issues and questions that arise. The new process will be outlined on a large education bulletin board on each unit and this will improve the visibility for easy reference. The third stage involves freezing or refreezing the process. In this stage the plan will be evaluated by auditing each occurrence. Management staff are required to audit all procedures and counsel with staff when deviation from the policy occurs. Knowledge and compliance with this policy will be demonstrated yearly
Healthcare organizations are required by their accrediting agencies to demonstrate methods of investigating sentinel events. Root cause analysis (RCA) is a systematic approach to investigating sentinel events used by institutions accredited by the Joint Commission. Once this process helps to identify the causes of the event and a plan to correct the causes, the failure mode and effects analysis (FMEA) is used to identify and decrease the ways the plan could fail. The task analyses these processes and the professional nurse’s role as a leader in the promotion of quality care.
A. Root Cause Analysis The RCA process is used when errors occur to identify potential prevention strategies. The …show more content…
The policy changes will outline the use of a checklist that includes a time out component to guide the staff through the process. The checklist will address: verify consent is obtained, all equipment available, IV is patent, reversal agents at bedside, respiratory therapist present, pre-procedure vital signs and assessment criteria. The time out component requires all staff to stop, agree upon and record: time, proper identification of the patient, the intended procedure, and laterality if applicable. Vital signs are obtained every five minutes during and after the procedure until the patient meets defined criteria (Huber & Ogrinc, …show more content…
Incorporating a change model to help guide the management process can help make the change successful. Kurt Lewin’s change model will provide the direction for this scenarios process improvement plan. This model proposes that change within an organization will occur in these stages: unfreezing, change, and refreezing. The first stage of unfreezing involves changing the current method of proceeding into a procedure without adequate communication and preparation to a process of forethought and safety. The staff will be included in the preparation of the new process, the education on its use, why the change is necessary and what it will accomplish. Research on quality improvements with the use of checklist and time-out will be shared with the staff. The second step involves the process of the change. This will be the most difficult stage for the staff and they will require a lot of support with issues and questions that arise. The new process will be outlined on a large education bulletin board on each unit and this will improve the visibility for easy reference. The third stage involves freezing or refreezing the process. In this stage the plan will be evaluated by auditing each occurrence. Management staff are required to audit all procedures and counsel with staff when deviation from the policy occurs. Knowledge and compliance with this policy will be demonstrated yearly