C489 Organizational Systems and Quality Leadership

C489 Organizational Systems and Quality Leadership

  1. Root Cause Analysis

Providing quality patient care is a basic tenant of nursing and medical practice today. To ensure the provision of the intended care, healthcare organizations must minimize errors and adverse outcomes resulting from an array of factors in hospitals. Root cause analysis (RCA) is an approach used to identify faulty systems during patient care alongside preventive measures to promote quality care. The purpose of conducting a root cause analysis is to protect patients by identifying challenging factors within healthcare that can harm patients (Charles et al., 2016). The process also seeks to understand how to fix, compensate, or learn from the events leading to the actual adverse outcome.

A1. RCA Steps

Conducting a root cause analysis is a stepwise approach that requires a team to effectively analyze the events leading to adverse outcomes. The Institute for Healthcare Improvement (IHI) describes six steps that can systematically identify system flaws while understanding more about the actual adverse event. The steps are listed below.

Step I: Identify what happened

Step II: Determine what should have happened

Step III: Determine causes

Step IV: Develop causal statements

Step V: Generate a list of actions to prevent recurrence of the event

Step VI: Share the findings

The first step involves the identification of the adverse event to create a platform for investigation. The RCA team that involves different members determines when the event happened, who was involved, why, and how it happened. Honesty and open reporting of adverse events are crucial to help generate the most appropriate solutions in later stages (Institute for Healthcare Improvement (IHI), n.d.). The second step involves determining what should have happened instead. This section is guided by clinical practice guidelines for solving healthcare problems and identification of what was not done right. An initial flow diagram can be used to identify how the situation could have been handled.

Step three of the RCA process deals with determining the actual causes of the adverse event. Organization of information is required to reach a mutual understanding of the problem. Triggering questions are used to guide further investigation while interviews with both parties can help generate the actual causes of the adverse event (IHI, n.d.). The next step involves the development of causal statements that summarize the whole event with clear identification of gaps. The team is charged with developing the problem statement and actions that caused the problem. Causal statements can be crucial in providing links between the patient and different healthcare teams that led to the adverse outcome.

The fifth step involves the generation of actions to address the actual problems that caused the adverse event. The selected team should identify barriers and risk reduction strategies to prevent the root cause from recurring. Multiple actions may be required to address different parts of the problem especially when many healthcare teams are involved (IHI, n.d.). The last step involves the communication of the findings to the staff involved and more broadly if applicable. The information shared should include things like the root cause, standard guidelines surrounding the issue, and proposed solutions to address the problem.

A2. Causative and Contributing Factors

The sentinel event describe involves Mr. B, a 67-year-old patient brought to the emergency department (ED) after sustaining a fall. The interventions made included moderate sedation to allow manual relocation and alignment of his left hip. However, a series of events during the procedure led to the deterioration of the patient’s condition and caused brain death a week later. The first cause of the problem was inadequate attention to the seriousness of the patient’s condition. Hip relocation and alignment is a simple procedure but requires extreme precaution because of sedation. Nurse J and Doctor T did not keenly take the patient’s history to guide the use of appropriate dosage during sedation. It was until later that Doctor T noticed the patient’s weight and the use of oxycodone prevented the timely achievement of sedation.

The second cause of the adverse event is the lack of adequate monitoring of the patient after undergoing the procedure. Nurse J and the LPN did not follow the protocol for patients recovering from sedation including continuous BP, ECG, and pulse monitoring. Perhaps, Nurse J should have assigned the patient to the LPN until full recovery instead of leaving the patient with his son. Another cause of the adverse event is understaffing in the ED leading to poor management of patients. It is observed that only two nurses were available to take care of a busy ED with patients that required specialized care. Failure to call for backup, despite its availability also led to mismanagement of Mr. B.

Contributing factors to the adverse event include an inadequate multidisciplinary approach to patient care and ignorance. For instance, respiratory therapy was in the house and available as needed but was not asked to help when the patient was desaturating. Nurse J and the LPN ignored the alarms that required the patient to be put on oxygen and assessed for possible respiratory depression. The RCA steps that helped to identify the causative and contributing factors include:

Step I: Identify what happened

Step II: Determine what should have happened

Step III: Determine causes

Step IV: Develop causal statements

  1. Improvement Plan

The first action to address the identified challenges should involve staff education on moderate sedation. Despite Nurse J and Doctor T’s diverse knowledge on the procedure, they failed to conduct proper assessment and monitoring of the patient. The education sessions should focus on the choice of drugs for sedation, proper dosage, and continuous monitoring of the patient after the procedure. The second intervention that can help address this situation is the formulation of a guideline for initiating a backup protocol during emergencies. Nurse J failed to realize when to call for backup despite the availability of additional staff to help. Handling too many patients in the ED eventually led to a lack of adequate monitoring of the patient and perhaps impaired decision making.

B1. Change Theory

Implementation of changes to address the sentinel event will utilize Kurt Lewin’s change management theory. The theory is composed of three stages that include unfreezing, change, and refreezing (Wojciechowski et al., 2016). The unfreezing stage involves the creation of awareness that new change is needed in the organization. This stage seeks to break down the status quo and challenge the attitudes, beliefs, and norms of employees. The change or moving stage involves the actual implementation of the proposed measures and the education of staff. Monitoring of the change is important to prevent employees from going back to the old ways (Wojciechowski et al., 2016). The refreezing stage functions to sustain the new change through actions like continuing education, monitoring, making policies, and rewarding employees. Feedback delivery is crucial during the refreezing stage to inform employees of their progress.

To apply this theory, the first step will involve the selection of members from different healthcare teams to implement the change. Staff will be informed about the actions leading to the sentinel event and how new approaches can help decrease the likelihood of the same outcomes. During the unfreezing stage, ED staff will be informed about the importance of taking the moderate sedation module and how it can help in making choices when performing the procedure. The change/moving stage will involve actual education of staff about the module including drugs to use and determining the correct dosages. ED staff will be monitored when performing the procedure to no note any errors and areas that may require improvement. The refreezing stage will involve continuous reminders of moderate sedation and patient monitoring during CMEs and formulation of policies in the ED.

  1. General Purpose of FMEA

Failure modes and effect analysis (FMEA) is a method used to evaluate a process to identify where and how it might fail and the relative impact of different failures. One of the reasons for conducting FMEA is to identify the parts of the process that are most in need of change (Institute for Healthcare Improvement (IHI), 2017). The process identifies potential risks and measures that can be implemented to enhance patient safety.

C1. Steps of FMEA Process

The Institute for Healthcare Improvement outlines five steps in the FMEA process. The first step involves the selection of a process to evaluate with FMEA. During this stage, it is important to divide larger or complex processes for the achievement of better results. Upon selection of the process, the second step involves the recruitment of a multidisciplinary team. The team will function to design assumptions, potential causes of the problem, and any past control measures that have worked (IHI, 2017). Step three involves listing all the steps in the FMEA process. Flowcharting can be a useful tool for visualizing processes. A nine-column table is proposed by the IHI to guide the team in identifying the failure mode, causes, effects, and other factors like assigning risk profile numbers (RPNs) (IHI, 2017). Step four will involve filling the table with input from all team members while the last step deals with assigning RPNs and using these numbers to plan improvement efforts.

C2. FMEA Table

Please see attached FMEA table.

  1. Intervention Testing

The proposed intervention involves the use of education and training of ED staff on moderate sedation and monitoring of patients after the procedure. To test this intervention, I will use the plan-do-study-act (PDSA) cycle. The PDSA cycle is a systematic process used to gain valuable learning and knowledge for continual improvement of a process (Coury et al., 2017). The Plan step involves identification of the goal, defining success metrics, and putting the plan into action. The Do step involves the implementation of the proposed plan while the study step involves monitoring outcomes to test the validity of the plan for signs of progress (Coury et al., 2017). The Act step closes the cycle and involves the integration of the generated learning, adjustment of goals, and changing methods.

During the Plan step, the goal will be to educate nurses on moderate sedation and monitoring of patients after the procedure. ED staff will understand the relevance of taking patient history and selection of sedative agents to prevent adverse outcomes. The Do step will involve the implementation of the plan and monitoring of staff to ensure all procedures are followed. The Study step will involve assessment of the progress, achievement of sedation, and the success rates resulting from the new plan in the ED. The Act step will involve further education of staff in areas that may seem to cause problems or change of methods if the plan does not work. For example, assigning specific nurses or more experienced personnel to monitor patients on sedation may bring about better outcomes.

  1. Demonstrate Leadership

The first area that a nurse leader can demonstrate leadership in promoting quality care. Professional nurses can be involved in formulating policies that can improve certain aspects of care leading to quality outcomes (Wagner, 2018). An example is a policy on improved staffing in the ER to minimize errors and delays in patient care. The second part is that a professional nurse can demonstrate leadership in improving patient outcomes. A professional nurse can identify and work with patients and families during care delivery to improve outcomes. For example, the involvement of patients and their representatives in committees and meetings can help to identify faulty systems that can be rectified to improve patient outcomes. Lastly, a professional nurse can demonstrate leadership through influence on quality improvement activities. An example is advocating for patients and staff regarding the adoption of technologies that can enhance healthcare outcomes (Wagner, 2018)). Engaging the administration in projects like the adoption of EHRs and other evidence-based research activities can improve quality in healthcare.

E1. Involving Professional Nurse in RCA and FMEA Processes

A professional nurse leader possesses different qualities that are essential to lead healthcare organizations to achieve set goals. Involving the nurse in the RCA and FMEA processes demonstrates leadership qualities in change management and effective problem solving (Wagner, 2018)). These processes provide the leader with an opportunity to come up with new strategies and methods to manage healthcare problems. Measures may include things like incorporating new technologies into patient care or improving staffing to address quality issues. Problem identification and solving using FMEA also demonstrate the nurse leader’s preparedness for poor healthcare outcomes and measures to improve the outcomes.


Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., Biermann, J. S., & Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: A review. Patient Safety in Surgery10(1), 1-5.


Coury, J., Schneider, J. L., Rivelli, J. S., Petrik, A. F., Seibel, E., D’Agostini, B., Taplin, S. H., Green, B. B., & Coronado, G. D. (2017). Applying the Plan-Do-Study-Act (PDSA) approach to a large pragmatic study involving safety net clinics. BMC Health Services Research17(1), 411. https://doi.org/10.1186/s12913-017-2364-3

Institute for Healthcare Improvement. (n.d.). Patient safety 104: Root cause and systems analysis.Retrieved from http://www.ihi.org/education/ihiopenschool/Courses/Documents/SummaryDocuments/PS%20104%20SummaryFINAL.pdf

Institute for Healthcare Improvement (2017). QI essentials toolkit: Failure modes and effects analysis (FMEA). Retrieved from


Wagner, J. (2018). Leadership and influencing change in nursing. University of Regina Press.

Wojciechowski, E., Pearsall, T., Murphy, P., & French, E. (2016). A case review: Integrating Lewin’s theory with lean’s system approach for change. Online Journal of Issues in Nursing21(2), 4. https://doi.org/10.3912/OJIN.Vol21No02Man04