How to Use the 5-Whys for Root Cause Analysis, Essay Example

Propose ways to improve interactions among personnel

In order to improve interactions, a risk assessment should be conducted of the current event, as well as over the staff procedures and practices relevant to the specific sentinel event. Procedures and policies should be regularly reviewed in order to consider throughout the organization any consistency. Procedures and policies should be clearly defined so that staff is aware of their duties and responsibilities, as well as how they can work together to assure patients’ safety. A culture of accountability and teamwork needs to be implemented in which the staff is educating in working as a team and knowing their specific roles in which they will be held accountable for violated practices.

A developed hand tool needs to be implemented to improve interactions and communication within different areas of the hospital. This is detailed below, as it will help in providing the staff with comprehension on the actions that affects other areas when receiving patients. Within the surgeon’s office there needs to be a procedure developed in which patient information or office notes to the registrar’s office at the ambulatory surgical center will be delivered (email, fax etc.). In doing so, this will help to guarantee that custody relevant information is provided to parties that are relevant to the office.  In trying to limit the virilities within the system, standardization needs to be provided. The staff’s external barrier should also be addressed in their expectations of their behavior at the beginning of the hiring process, and throughout their employment.

Within the Registrar’s office, the office must include a checkbox during the registration process in which covers the registration paperwork in order to provide signatures for involved parties. As well as handoff information and discussion for permissible emergency contacts and custody information. Within the ambulatory surgical center, the registrar should always for each patient complete a face-to-face handoff. To improve communication in the pre-operative area, the registrar office should oversee the hand off confirming the patient information with all parties involved. The pre-operative area should also confirm for any approved parties contact information. Within the patients’ charts and the staff’s personal documentation, additional contact information should be provided. Within the operative area, the pre-operative area should oversee the handoff of patient information that is confirmed by all parties. The recovery area should also communicate with the operative are in which they will provide the recovery area with the handoff of patient information. In which allow the approved designee or parents of the patient at their bedside. The requirement for access to minor patients is a photo ID, and any non-staff member must have approved documentation from a legal guardian or parent, and within the patient’s records. The discharge nurse should receive the handoff within the recovery area, in which the legal guardian or parent would hand off, so that parties would know who has access to the patient. A legal guardian or parent with the oversee of the staff should verify the discharged patient’s confirmed party. The security should develop a procedure in which in the event of a potential abduction have a plan in place. Training of security should occur biannually in order to deal with new scenarios, and prepare security. The administration and the nursing CEO should also provide support to training the security, staff, and nurses in which these policies and procedures are relevant.

Discuss a quality improvement tool to be used in conducting Root Cause

Several quality improvement tools can be utilized within the organization that is relevant to the sentinel event. A root cause analysis (RCA) tool permits the hospital staff to identify the causes for variations in the system’s performance that could lead to an event that is unanticipated. Failure, Mode, and Effects Analysis is another possible tool to be utilized, in which permits staff to assess the system’s risk and put a plan into action in order to mitigate any potential risks. (Tilburg, Leistikow, Rademaker, Bierings, and van Dijk, 2006) In this particular event, this tool is recommended in which will coincide with the system already in place. This is a continuous process that offers several implemented solution in which effectiveness can be measured.

The team will consist of available surgeon, discharge nurse, post op nurse, recovery room nurse, OR nurse, pre-op nurse, security, the registrar, and leadership that is provided by the Chief Nursing Officer. During the process of the planning phase, the team will be able to collect baseline data, review the current process, and readily identify any problems. The utilized tools are brainstorming and process mapping. Identifying the problem’s root cause is the next steps. By creating a cause and effect diagram to be utilized to document identified issues using the process of “5 Why”. (Sonadalini, n.d)  Once the identified issues relevant to the sentinel event are display, the team will create a plan for the solutions to be implemented in the identified areas. Future state process maps and brainstorming are used in this phase in which barriers to implementation and the solutions to the identified problems will be examined. In order to measure the success of the process, process improvement measures will be identified.

The next part of the phase is to put the implemented solutions into effect and test it out to see results. In determining areas of improvement within the system, the team will discuss the results of the conducted tests. The results will be studied and measured again until the desired results are achieved. The achieved results will be standardized into the system in order to prevent any potential problems so that the trained staff follows developed procedures. The tools for measuring quality will be used continuously so that to ensure that there is not a breakdown in the process, and improvements are consistently made.  Existing description of personnel roles and responsibility – these should be reviewed by hospital administrators and the hospital board to see if they needed to be revised and updated. Then they need to communicate any changes made to the staff. The staff should also see the roles and responsibility of other personnel involved so that they have an idea how their role fit in this entire process. The staff should also sign and date this form acknowledging that they have been given the information and understand their culpability.

If the patient is under age, a parent or guardian’s contact information should be on the wristband. Registration should confirm this with the parent at check-in. If this system had been in place, the mother’s cell phone number would have been on the wristband so the moment it was found out that she was not around when the patient was in recovery, someone would have tried to get hold of her.

Corrective Action Plan to Avoid a Sentinel Event

Using the information provided in the prescribed chart, the team has identified that bracelets or bands are needed for infants and minor patients within the areas of the hospital. The bracelets are alarm activated in the event that there is an emergency. In getting matching bracelets for parents or guardians, the administration should retain a copy of the person’s photo identification to be placed on the medical record of the patient. The parent will be provided with an identical bracelet as the patient, in which the patient would only be discharged if the parent has the matching bracelet. This policy should be immediately implemented throughout the hospital. The Patient Safety Officer will handle the responsibility of educating the staff in the policies and procedures of the hospital. The banding and policy procedures would be applied to every department that deals with minor patients throughout the facility. The Patient Safety Department would also conduct observations in areas of the facility in order to determine if the staff is complying with the standardized policy. As well, will work with Materials Management that will be in charge of providing each department with bands relevant to their area.

In the providing corrective action to the lack of communication in the areas of the facility. The plan is recommended that the staff follow the SBAR format in which will be used throughout the entire stay of the patient, as they are completely handed off to the parent. The SBAR format (Safer Healthcare, n.d) follows the procedure of identifying the situation, providing a background, creating an assessment and providing a recommendation to solve the situation. It not only promotes patient safety, but also quality, and overall increased communication with physicians and staff.  This tool will be used in obtaining the patient’s escort, the nursing on-call number, and place where documents can be easily transported. The improved communication would permit the staff to know each member’s responsibilities, and be accountable for handoff completion. Each month, a sample of records will be audited for quality assurance. The staff would, also utilize a checklist of information with the medical records of the patient, in an effort to reduce the risk to the patient and the hospital. The checklist would serve as a reminder to the staff on the information that is relevant to the patient’s safety and care.

In implementing the new procedures, the staff would be first assessed in the first six weeks in order to get feedback, and measure the effectiveness. The assessment will help in making improvements to the system that will help in the standardization process throughout the organization. The staff will be regularly trained in the new policies and procedures, as well as the expectations required. Educational services will perform tracer audits over 30 patients each month in order to review handoff tool, which will be used in providing feedback to improvement in the policies. This will guarantee that procedures are followed, and staff takes the changes and responsibilities of caring for the care and safety of patients seriously.

B1A Resources

The hospital is more than equipped with resources that will guarantee the desired results for the newly implemented policies. The team will be provided with ongoing leadership support and a revamped accountability system for staff members. The staff is committed because patient safety and quality care are the number one priority. The Educational Services that is a part of the Senior Leadership in conjunction with the Department Management will be in charge of performing audits as part of the ongoing review of patient safety, and review of medical records. Educational programs will also be developed in order to review the needed educational material on patient safety, and improved communication between the staff. For the purchase of additional bracelets, money has been allocated from the budget that will cover providing parents with identical bracelets. Security will be regularly trained in handling non-custodial and custodial parents/legal guardians, as well as issues related to security. They team also believes that within the time allowed they have the provided resources to make improvements.

The Senior Leadership team was presented with the proposed project, and the CEO found that all opportunities were explored by the team. The CEO believes that if a similar sentinel event were to occur, the child would not be allowed to go home with the non-custodial parent. The team has provided a well-researched and effective plan of action. The CEO, as well as the Senior Leadership Team, believes that patient safety and care are the main priorities of the organization, and improvements to the system should be a standard for present and incoming medical staff members.

References

Sondalini, Mike. (n.d). Understanding How to Use the 5-Whys for Root Cause Analysis. Lifetime Reliability Solutions. Retrieved from http://www.lifetime-reliability.com/tutorials/lean-management-methods/How_to_Use_the_5-Whys_for_Root_Cause_Analysis.pdf

Why is SBAR Communication So Critical? (n.d). Safer Healthcare. Retrieved from http://www.saferhealthcare.com/sbar/what-is-sbar/

Van Tilburg, C. M., Leistikow, I. P., Rademaker, C. M. A., Bierings, M. B., & van Dijk, A. T. H. (2006). Health care failure mode and effect analysis: a useful proactive risk analysis in a pediatric oncology ward. Quality & Safety in Health Care, 15(1), 58–63. doi:10.1136/qshc.2005.014902