Organizational systems and quality leadership

Nursing

Organizational Systems and Quality Leadership

Due to the sentinel event that occurred a root cause analysis is being conducted. In this case the problem that must be looked at is that of how Mr. B went from resting without any indications of discomfort or distress to not breathing and having no palpable pulse in a matter of fifteen minutes.

After the completion of the reduction of the patients (L) hip at 4:30 he is placed on an automatic blood pressure machine that is programmed to monitor his blood pressure every five minutes and a pulse oximeter. He was not receiving supplemental oxygen nor was his ECG and respirations being monitored. The current hospital moderate sedation/analgesia ("conscious sedation") policy requires that a patient remain on continuous B/P, ECG, and pulse oximeter throughout the procedure and until the patient meets specific discharge criteria. This criteria includes the patient being fully awake, VSS, no N/V, and able to void. This criterion was clearly not being met by Mr. B.

Another issue that needs to be looked at is the fact that a 4:35 when the staff left Mr. B's room his B/P was 110/62 and his O2 sat was 92%. When the alarm is heard and the LPN enters Mr. B's room it was registering "low O2 saturation," the machine was reading a sat of 85%. The LPN reset the alarm and repeated the B/P reading, but never addressed the low O2 saturation warning.

At the time that this was all going on Nurse J. And the LPN on duty has received an emergency transport patient. They are also in the process of discharging two other patients and the ED lobby has become congested with new incoming patients. Even though there was additional back up staff available on this particular day, no one was called.

The first question that must be asked is why was the hospitals moderate sedation/analgesia policy not adhered to? The policy clearly states that the patient must be on continuous ECG until a set of pre-defined criteria are obtained. Mr. B was not at this point and should have never been without the ECG. The second question that must be looked at is that of why it was when the alarm went off the first time did the LPN simply reset it instead of addressing the low O2 warning that was being presented. Hospital policy dictates that all practitioners who perform moderate sedation must first successfully complete the hospital's moderate sedation training module. It is stated that Nurse J. had successfully completed this training but there is no mention that the LPN had done so. The low O2 warning should have been addressed by someone, like Nurse J, who was properly trained in this area.

The last question that should be raised is that of why it was if there was available back up staff that could have been utilized when the ED became busy, why was this staff not called upon? Is there a certain point at which staff is required by hospital policy to call in reinforcements and who is it that is supposed to make this decision? Working under extremely busy circumstances greatly compromises the quality of care that is given to the patients. If there is something that can be done to alleviate the situation then it should be done.

In the case of the death of Mr. B, there are several causes that need to be remedied in order to prevent recurrence. The first is that all hospital procedures and policies need to be not only well documented then need to be assessable to all who need them. They need to be adhered to at all times and employees need to be held accountable for knowing what the SOP's are and when they should be followed. A second cause involves the fact that all personnel that will be working with patients need to be fully trained in all procedures that they will need to carry out their job function. If a person finds themselves in a situation in which they have not been properly trained then they need to refer to a policy that needs to be in place to consult with someone who is in order to make sure that proper care is being delivered at all times.

In the early 20th century, a psychologist by the name of Kurt Lewin identified three stages of change that are still used in many changes theories today. The three phases are unfreeze, transition and refreeze. A basic inclination of people is to seek a situation in which they have relative safety and feel a sense of control. When they establish themselves, they often attach their sense of identity to their environment. This creates a relaxed stasis from which any alternatives, even those which may offer significant benefit, will cause discomfort. Unfreezing people from this phase usually requires push methods to get them moving, after which pull methods can be used to keep them going (Lewin's freeze phases, 2010).

A key part of Lewin's model is that change, even at the psychological level, is a journey rather than a simple step. This journey may not be that easy and the person may need to go through several stages before they get to the other side. Transitioning requires time. Leadership is very important to the entire change process. Some structure of coaching, counseling or other psychological support will often be needed to help with the transformation. People often become comfortable in temporary situations where they are not accountable for the hazards of normal work and where talking about change may be substituted for real action (Lewin's freeze phases, 2010).

At the other end of the process, the final goal is to refreeze. This consists of putting down roots again and establishing the new place of stability. In reality, refreezing is often a slow process as transitions seldom stop cleanly. They go more in fits and starts with a long periods of bits and pieces. There are good and bad things about this. The hazard with this that many organizations have found is that people fall into a state of change shock. This is where they work at a low level of competence and effectiveness as they await the next change (Lewin's freeze phases, 2010).

When applying change theory to the current situation it is important to make sure that each of these three phases are included in a change plan. It can be seen in this situation that the staff has achieved a comfortable stasis from which any alternatives, even those which may offer significant benefit, will cause discomfort. The key to this phase is convincing the staff that things are not working the way that they being done and that things need to be changed in order to improve the situation. There would be a need for a push in order to get these people talking. A good way to start would be to form a process improvement committee that could look into what standard operating procedures are in place but need to be updated. It would also need to determine what procedures, if any, are missing and need to be defined. A process that would need to be done would be to come up with a way to distribute these procedures to the staff so that they can be held accountable for receiving them.

Once the review of the standard operating procedures has been completed then they need to be distributed to each employee and training sessions need to be held. This transition phase will need to be carried out by leadership in order to make sure that everyone is on the same page. This is also the appropriate phase in which to incorporate some form of coaching, counseling or other psychological support in order to help employees embrace the idea of change. It would need to be enforced that the process improvements that are being undertaken are for the good of everyone, but are especially good for patient safety and satisfaction. Everyone needs to embrace the changes that are taking place because patient safety should be the top priority for the hospital and situations like the one that occurred with Mr. B, should never happen again.

At the point in time that the processes and procedures have all been defined, documented and delivered to the staff it is time to move into the refreezing phase of the change process. This phase will involve making sure that everyone is following the processes that have been established. There will need to be some sort of measurement instrument devised in order to monitor this. This could consist of random audits being done by leadership to make sure that everything is being done correctly. There would need to be both a system of rewards and punishment that would be adhered to as a result of these audits. In order to make sure that employees buy into the changes that are being put forth they must know from the beginning that there are consequences and that they are going to be held accountable for their actions.

After the change process has been developed a failure mode and effects analysis (FMEA) would need to be done. This analysis is done in order to project the likelihood that the process improvement plan will not fail. The interdisciplinary team for this entire process will consist of an emergency room physician, an RN, an LPN, a clinical quality consultant, an HR representative and an a patient safety advocate.

The process for conducting an FMEA is straightforward. A sturdy analysis can be obtained from interface matrices, boundary diagrams, and parameter diagrams. A lot of breakdowns are due to noise factors and shared interfaces with other parts or systems. In order to begin it is necessary to describe the system as a whole and its function. A good understanding simplifies further analysis. This way a person can see which uses of the system are desirable and which are not. It is imperative to consider both intentional and unintentional uses. Unintentional uses are a form of hostile environment (Crow, 2002).

The second thing to be done is the creation of a block diagram of the system. This diagram gives a general idea of the major components or process steps and how they are related. These are called logical relationships around which the FMEA can be developed. It is useful to create a coding system in order to identify the different system elements. The block diagram should always be included with the FMEA. Previous to starting the actual FMEA, a worksheet needs to be created. This should contain the significant information about the system, such as the revision date or the names of the components. Included on this worksheet should be all the items or functions of the subject listed in a logical manner, based on the block diagram (Crow, 2002).

There are three basic steps of a FMEA. The first is that of Severity. In this step it is necessary to determine all failure modes based on the functional requirements and their effects. It is essential to note that a failure mode in one component can lead to a failure mode in another component. So each failure mode should be written down in technical terms and for function. After this the ultimate effect of each failure mode needs to be considered. A failure consequence is defined as the result of a failure mode on the function of the system as perceived by the user. In this way it is opportune to write these effects down in terms of what the user might see or experience (Crow, 2002). Putting this into perspective to the situation with Mr. B, there was a failure to follow proper procedures in regards to the conscious sedation policy. There was also a failure in communication between the LPN and Nurse J. along with a failure of communication between the staff in the emergency room and the backup staff that was in place to assist.

The second step is that of Occurrence. In this step it is essential to look at the cause of a failure and how many times it occurs. This can be done by looking at like products or processes and the failures that have been documented for them. A failure cause is seen as a design weakness. All the possible causes for a failure mode should be identified and documented. Again this should be in technical terms (Crow, 2002). In this case back incident reports would need to be looked at to determine the amount of times that these types of failures have occurred in the past.

The third step is that of Detection. When suitable actions are determined, it is necessary to test their efficiency. Also design verification is required. The proper inspection methods need to be chosen. One should put into place testing, analysis, monitoring and other techniques that can be or have been used on similar systems to detect failures. From these controls it can be seen how likely it is for a failure to be identified or detected (Crow, 2002). Testing of the new processes and procedures that have been put into place in the hospital will need to be done with simulations being conducted in order to make sure that the proper procedures are realized and carried out. Situations like the one with Mr. B could be recreated and acted through to make sure that all the proper steps were being done. This is the phase that can help identify gaps that are in the plan and whether these gaps are likely to cause failure of the entire plan. Gaps that are identified would then be fixed in order to prevent the implemented plan from failing.