Organizational Systems and Quality Leadership

Organizational Systems and Quality Leadership

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

A Root Cause Analysis refers to an approach characterized by investigative strategies aimed at understanding individual events. According to Latino, Latino, and Latino, (2016), the Root Cause Analysis examines these factors in accordance with their contribution towards a given development. The importance of conducting a cause analysis is because it provides the analysts with the opportunity to identify the primary source of problems. The steps involved in the Root Cause Analysis areas outlined below.

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

Step 1: Organize Team

The first step in undertaking a cause analysis is to develop a team of responsible members for obtaining solutions to a specific issue. According to Latino, Latino, and Latino, (2016), the team is made up of persons who are either directly affected by the problem identified or are involved in the same. The roles of these stakeholders should be defined at this stage to ensure that no conflicts may arise as to whom a was some characters given. The leader should also be selected in at this point to have some form of leadership and ensure regulations set forth are followed.

Step 2: Define the Problem or Issue

The second step involves the identification and definition of the challenge faced that requires a solution to be obtained. The impacts of the issue, both positive and negative are outlined in this stage, and each of the stakeholders provides their insights about the problem. The extent of the effects of the problem is also discussed at this stage. Latino, Latino, and Latino, (2016) indicate that brainstorming may commence from this stage to identify the possible causes of the problem, but the discussion of these causes is not done at this stage.

Step 3: Conduct Data Analysis

By this stage, data concerning the problem has been identified. The extent of the effects of the issue to the concerned party/organization is already known and can be analyzed. However, new data streams in from activities such as interviews, observations, reviews, records and other data sources. The data is then analyzed to objectively identify the patterns involved, trends, a and variability. Brainstorming is also undertaken at this stage to try and narrow down to the specific causes of the problem, but discussions on the same are not done.

Step 4: Determine the Root Cause(s)

This is the stage in which the cause of the problem is identified. Based on the party/organization in context, the strategy to use in identifying the cause of the challenge may differ. However, the most common approaches involve the brainstorming and discussion of findings from the identified trends, patterns and variability of data examined. Geerling, Chernofsky and Pratt, (2014) notes that the cause may be one, but the same can be many, and hence the stage should not be limited to identifying a single cause. The stakeholders must agree on the identified cause(s), and confirm that the cause is clear and logically identified.

Step 5: Improvement Planning

The Improvement plan is a strategy reflecting on the correction of or suggestion of an intervention to solve the identified cause. The improvement plan must ensure there is a logical link between the solution and the identified issue; there are both long-term and short-term outcomes and deliverables and action steps to integrate the plan. Consequently, personnel from the team developed are assigned the duty to develop, monitor and evaluate the plan for improvement while collecting data for future evaluations.

Step 6: Evaluation Process

Evaluation is the final stage in the Root Cause Analysis. According to Latino, Latino, and Latino, (2016), evaluation is conducted to evaluate the effectiveness of the improvement plan in alleviating the problem identified. Similarly, the evaluation plan examines if the problem is solved and if there is need to review the plan to accommodate more interventions for the problems to be fully solved. Also, the evaluation process examines the probability of the issue occurring again in the future to provide the team with a chance to strategize on how to either plan to avoid the issue or develop a plan to solve the problem.

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

Regarding the provided case, the contributing factors that are identified are the failure to conform to the policies of the healthcare facility, and conscious sedation of the patients. For instance, one of the supporting evidence is that the patient was not connected to the Continuous ECG monitor while he was hospitalized. Also, his vitals, respiration, and stages of recovery had not been monitored in the course of his treatment. The error is among the causative agents of the problem since the health care practitioners did not conform to the healthcare policies and regulations presented by the hospital, thereby failing to meet the concerns of the patients. The nurses who were involved were knowledgeable on the hospital policies and regulations but failed to practice the same while under sedation.

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

The process improvement plan that would be used in ensuring the likelihood of the scenario reoccurring is to utilize the advanced technology gadgets that can remind the nurses on timelines for monitoring the patients. For instance, after conscious sedation, the nurse responsible for a specific patient should use advanced technology watches set the timeline on when the sedation should be don conducted. Similarly, the patients should be fitted with a bracelet or watch synchronized with the nurse’s watch to show the other nurses who may monitor the patients on when next the patients should be medicated next.

Also, through the use of CCTV cameras to monitor the patient’s activities while in the admission rooms. Accordant to Geerling, Chernofsky and Pratt, (2014), the use of the cameras will ensure the patients can be monitored from a central place and hence having the system continually monitoring the activities of the patients and hence reducing the likelihood of the error occurring again in future.

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


This is the first phase that is involved in the change process of humans. In this stage, the humans are prepared for and to accept the change needed. As such, the individual must understand that his actions were wrong and there is a need for him to change. According to MindToolsVideos (2014), the first phase of Lewin’s Change theory is directed to ensure the people involved put aside the behaviour bringing the conflict and hence working towards the change. For the case, the nurses who were not monitoring the patients can be invited to a meeting to discuss their failure to monitor the patients, the implications arising and why it is important for them to adjust their activities and behaviours and monitor patients well in future.


According to MindToolsVideos (2014), this is the stage where resolutions are made, and new approaches are integrated to ensure proper outcomes are received. However, the change may not be instant but may take some time before the change process is fully achieved. For the case of failure to monitor the patients, this is the stage where the nurse begins to practice how to monitor the patients better and utilizing the gadgets that assist in the process.


The final stage in Lewin’s Change model is the refreezing stage, where, as changes are taking place, the people embrace the new ways integrated and hence freeze comfortably on the aspect. For the nurses, they are to continue with the behaviour of using the gadgets in monitoring the patients over time and hence will freeze on this aspect due to the continuous conducting of this activity.

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

FEMA refers to an analytical process that evaluates and examines the possibility of future accounts of a failure in any process and hence understand the dynamics involved and why the issue occurred (Cherry, & Jacob, 2014).

  1. Describe the sevensteps of the FMEA process.

The first step of FEMA is the selection phase where the process to be evaluated is selected, and a team for evaluating the same is formed. The team formed is usually a multidisciplinary team. The second step is to select a leader to direct the team to the process. The third step involves the identification of steps to be followed by the team and discussing how to follow the same. The fourth step in the FEMA is to list the causes and failures as a numeric value representing the likelihood of the problem occurring in future. The fifth step is assigning the failure models the numeric value, with the sixth step being the evaluation of the identified

Steps in the Improvement Plan Process * Failure Mode Likelihood of Occurrence
Likelihood of Detection


Risk Priority Number



Doctor orders medication for pain before the invasive procedure.


Wrong medication selected 3 5 5 75
1.Patients do not have proper access to oxygen. Incompetence of the Nurse 3 4 5 78
2.The failure of the nurse to remember hooking the patient to the ECG Incompetence of the Nurse 2 6 8 69
3.Filure of nurses to monitor the health outcomes of the patients. Nurse Incompetence 5 7 7 76

results. Finally, the seventh step is to develop a plan for the RPNs to use in improving the

Outcomes identified.

  1. Apply the last four steps of the FMEA process by completing the attached “FMEA Table,” based on the proposed improvement plan and using the scales of severity, occurrence, and detection.


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

Testing the intervention will be done through the examination of how the monitoring is conducted. If the level of monitoring of the patients is done at a high rate and within short timelines without failure, then the proposed solution is successful. However, if the same is not conducted effectively, it means that the intervention plan was not successfully implemented. Also, feedback from the patients will be useful in identifying if the plan was successful. Positive reviews and feedback will ascertain that the plan was successful, while negative feedback and reviews will indicate that the plan was not successful.

  1. Key Roles of Nurses

In the nursing profession, it is paramount that the nurses prioritize the outcomes of the needs of the patients for effective care. The nurses must ensure to align their services with the available resources to meet the needs of the patients and prioritize the care of the patients. Also, the nurses must work together with other professionals in a healthcare institution for the needs of the patients to be met. When nurses are involved with the FEMA and RCA, it shows that they have the leadership qualities and can lead the healthcare setting to identify problems, their solutions and intervention plans through critical thinking and teamwork.


Cherry, B., & Jacob, S. (2014). Contemporary Nursing: Issues, Trends, & Management (6 ed.). St. Louis: Elsevier Mosby.

Geerling, J., Chernofsky, M., & Pratt, S. D. (2014). Root Cause Analysis. ASA Newsletter78(6), 46-49.

Latino, R. J., Latino, K. C., & Latino, M. A. (2016). Cause analysis: improving performance for bottom-line results. CRC press.

MindToolsVideos (Director). (2014). Lewin’s Change Management Model: Kurt Lewin’s Unfreeze-Change-Refreeze Theory [Motion Picture]. Retrieved from Mind Tools:


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