Organizational Systems and Quality Leadership in Healthcare

free essayThe patient safety problems can be classified into term errors, communication failures, inappropriate patient management, and low-quality clinical performance before, during, and after the patient’s intervention. Root cause analysis can help to identify current problems in healthcare process.

Root Cause Analysis

According to the scenario, Mr. B’s death was caused by wrong actions made by the LPN on duty.  Since the hospital policy requests the importance of successful completion of the hospital’s moderate sedation training module for all practitioners, the LPN on duty was not responsible to repeat the B/P reading, when the nurse J was busy with the other patient. In terms of the classification of the types of errors and harm, there was an active failure based on the direct contact of the LPN on duty with the patient Mr. B. Thereby, the main problem is wrong actions of the LPN on duty, which cause the death of Mr. B. Indeed, it is more problematically, since Mr. B has only broken his leg and was resting after the sedation, when the problem occurred. There are several issues connected with the incident.

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The first problem is that LPN on duty was not responsible to provide care for the patient (repeat the B/P reading) since he had not completed moderate sedation module. The second problem is that the patient was sleeping when the B/P procedure was repeated, even despite the fact that hospital sedation policy requires that the patient should meet specific discharge requirements (i.e. fully awake, VSS, no N/V, and able to void) during the B/P procedure. The third problem is that trained nurse was not available for the patient, who was being monitored via blood pressure monitor. The next problem is that LPN on duty did not call the emergency department physician or trained nurse for the patient, when the monitor began to alarm.

All mentioned problems have several causes connected with the medical aspects of patient care. First of all, it is the lack of adequate trained personnel. For example, for sixty-bed rural hospital, there was only one nurse, who had completed moderate sedation module, and there was only one emergency department physician. Secondly, the next cause of the existent problems is the lack of adequate training facilities for the available personnel. Thereby, the LPN on duty was not able to provide proper care for the patient.

Improvement Plan

The patient care improvement is a dynamic process and should be based on the appropriate improvement plan. In order to achieve this objective, the development and sustenance of a patient-sensitive system should be provided. Thus, it is necessary to pay attention to quality in every aspect of patient care, both medical and non-medical ones. A proposed improvement plan is to decrease the likelihood of the given scenario problems reoccurrence. Thus, in order to prevent recurrence, the next specific changes were recommend.

First of all, there is a need for increasing the number of staff training programs and improving the existing ones. Thereby, new and improved training programs will cause the increase in the number of the trained staff responsible for high-quality patient care. Secondly, the use of newer technologies is important for improving the existent level of the patient care quality. It is also necessary to mention, that these described improvement steps should be done with reference to cost efficiency.

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On the other hand, the care process should also be improved, since previously mentioned patient safety problems were classified in terms of errors because of the communication failures between the LPN on duty and other emergency department staff.  In order to provide better communication system between the staff members, the next steps should be implemented. The first step is to provide staff with such communication technologies as working telephones or radios. This will allow speeding the communication processes between the staff members in different parts of the emergency department. The second step is to provide clear recommendations about the delivering health care. For example, it is important to mention to new staff, especially to interns and the like, that if they are not responsible for some procedures, they need to immediately call the responsible nurse or physician.

Change Theory

A change theory is the general concept of developing the specific areas of the improving healthcare processes in the organization. Creative use of different change concepts will help to develop a specific knowledge for implementing changes throughout the organization. According to Langley et al. (2009), a useful change theory for the given case is the concept of improving the workflow and error proofing. For instance, improving the workflow will allow constructing the process steps that will help to speed it and obtain proper quality at lower costs. Indeed, the error proofing will help to avoid mistakes in delivering health care (Institute for healthcare improvement, 2013). For example, errors could include wrong dosage of medication or improper medical staff behavior that can lead to the complications in the patient’s health.

Failure Modes and Effects Analysis

Failure Modes and Effects Analysis (FMEA) is a method for evaluating healthcare process. In order to identify the parts of the process that are most in need for a change, the FMEA identifies where and how it might fail and assesses relative influence of  different failures (Institute for Healthcare Improvement, 2004). Thus, the FMEA provides substantial support to imagine how successful the improving plan will be. This method is based on describing the following part of the improvement plan. The first part contains steps in the process; the second part contains failure modes, which describe what could go wrong; the third part describes the failure causes, which answers the question, why would the failure happen; and the fourth one characterizes the failure effects that contain the consequences of each failure (Institute for Healthcare Improvement, 2004).

Members of the Interdisciplinary Team

The interdisciplinary ieam consists of four members, who were defined as the most active healthcare staff. In order to provide the effective changing process, this team contains every profession involved in delivery of the healthcare process from those who regularly perform it. For example, it is consisted of the nurses’ supervisor, emergency department physician, and two nurses working in shifts. The physician from the other emergency department was chosen as a representative of the process. The leader of the team is the head of the district’s health department.

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Furthermore, the steps that occur before the actual FMEA begins are described below. The first step in the Failure Modes and Effects Analysis is the selection of the process to evaluate (Institute for Healthcare Improvement, 2004). As it was mentioned in the part “A. Root Cause Analysis”, the process that requires improvement is training of new staff responsible for high-quality patient care. This will help to avoid many problems that have been created because of the wrong actions of medical staff.  The second step is to recruit an interdisciplinary team (Institute for Healthcare Improvement, 2004), which was described in part “C1. Members of the Interdisciplinary Team”. The third step of the FMEA preparation is to conduct several meetings between the team members, where they will list all the steps in the evaluation process.

Three Steps

The next stage of the FMEA is defining the severity, occurrence, and detection ratios of the existed problems. The severity rates include important elements for the organization, such as providing high safety standards. Severity rating shows the possibility of the harm occurring in the case of the failure mode. Its score may vary between 1 and 10, and the higher score is, the higher is the possibility that severe harm will occur.  In case of the given emergency department, the fault will cause the death of the patient. Thus, such failure mode as staff mistakes should have 10 score in severity rating (Carlson, 2014).

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The occurrence rating defines the probability of a failure that occurs during the expected lifetime of the service (Carlson, 2014). Thus, this indicator is based on a functional breakdown of the healthcare system in the emergency department. For example, it can predict the possibility of the fact that nursing staff will make a mistake in the care process.

The detection ratio characterizes the probability of detecting the problem. It also includes isolating the problem and maintaining time (Carlson, 2014). For example, in the described problem, it took 7 minutes to find that the LPN on duty has made a mistake which cause the deterioration of the patient’s health. However, it did not help to prevent death of the patient.


Plan-Do-Study-Act (PDSA) cycle is an appropriate method for testing the quality improvement before its overall launching throughout the organization. The first stage of the PDSA is the plan stage. It occurs at the planned meetings, which were described in the part “C2. Pre-Steps”.  At the second stage of this cycle, an interdisciplinary team should carry out a small-scale test of the planned action. During this stage, they need to observe and document any unexpected events or problems and collect data. This data then will allow determining the impact of the test on the improving plan (Langley, 2009). The third is the study stage. During this stage, the team members should analyze the collected data and observations, and compare these findings to the expected indicators.  The last stage is the acting. During this stage, the improvements to the plan are made. Further, the team members can also decide either to proceed to full-scale implementation or again to test the change with some modifications (Langley, 2009).

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Key Role of Nurses

Senior nurses play important roles as leaders who help shape healthcare quality and patient safety (Middleton, 2011). They also should provide successful introduction and implementation of advanced practice nursing roles in their organizations. Nowadays, nursing role in influencing all aspects of healthcare delivery is increasingly growing. For example, senior nurses should develop other employees by enabling them to apply theory to healthcare practice. Furthermore, they need to encourage them to test new skills in a safe and supportive environment, which will help them to improve patient safety. Indeed, nurses also need to resolve tensions between professional disciplines and build an effective relationship between the interdisciplinary team members (Middleton, 2011).


The root cause analysis allowed dividing existent problems in the emergency department in terms of healthcare delivering services. According to it, the major problem of this organization is the lack of the qualified staff being responsible for complex medical operations. As a result of the failure modes and effects analysis, an appropriate improvement plan was developed.

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