Organizational Systems and Quality Leadership

The country I chose to compare with the United States healthcare system is Japan. Access to healthcare in Japan is fairly easy. Every individual, including the unemployed, children and retirees, is covered by signing up for a health insurance policy. They can obtain insurance either through their work or through a community based insurance. For those Japanese citizens that are too poor to afford health insurance, the government supplies their insurance through a social insurance. If a Japanese citizen loses his/her job and becomes unemployed, the individual will just switch to a community

Root cause analysis process will utilize a systematic step-by-step approach to help identify all causative factors leading to this sentinel event. The main purpose of the Root Cause Analysis is to understand how the event happened, why did it happen, and what can be done to prevent an event from happening again. The first step, collect all necessary data associated with this event such as: current policy and procedures, incident report, Mr. B’s health history, environmental flowcharts, dispensed medications, equipment and staffing factors relevant to the event. The process of identifying causative factors can begin once all the data is collected. The goal, of a Root Cause Analysis, is to identify interventions to prevent an event from reoccurring.

Sentinel event refers to the occurrence of serious physical illness or death or psychological injury or even those incidences whose recurrence involves risks with adverse and serious outcomes. It may result into deaths that are not anticipated or permanent loss of a major function that is not associated with patient’s natural cause of illness or condition (Lewis et al, 2014). The causative factors of Mr. B’s demise, according to the scenario described are that Mr. B was not put on oxygen or an EKG monitor

The goal of this paper is to scrutinize the regrettable sentinel event of Mr. B, a sixty-seven-year-old patient who was admitted to a rural ED with left leg pain that he found unbearable. A root cause analysis will be used to exam the causative factors that led to this unfortunate sentinel event. Then I will identify the errors or hazards in the care of Mr. B. A change theory will then be utilized to establish a useful improvement plan that would hopefully decrease the chances of a repeat of the outcome in the Mr. B scenario.  A Failure Modes and Effects Analysis (FMEA) will then be

A root cause analysis (RCA) looks at an event and considers what happened, why it happened what will be done to prevent it from happening again and how will we know that the changes made will improve the safety of the system. It takes into consideration causative factors, errors and hazards that led to a sentinel event. In this case it was a patient’s death. RCA should not look to place blame on people, but rather processes that need to be improved.

As defined by the Joint Commission (2014) a sentinel event is an unexpected occurrence involving death, or serious physical, psychological injury, or the risk thereof. With this said Nightingale community Hospital recently experienced a sentinel event

Root cause analysis (RCA) is used in different fields to conduct a systematic search to find the causes of a specific sentinel event (Jacob, 2010).  The main goal for conducting a RCA is to prevent similar adverse events from happening in the future (Jacob, 2010).  In this paper, I will use the scenario provided in the task to create a complete RCA report as well as improvement plans that will prevent similar incidents from happening again.

The theory also requires us to answer three basic questions, which are: What to change? What to change to? How to cause the change?

After finishing interview with standardized patient, I explained everything to my group members and they updated the patient medication chart with necessary changes with discrepancies we found out including plan we came up to implement those

Improvement plan must be in place in order to decrease the likelihood of a reoccurrence of the outcome of the Mr. B scenario. The model for Improvement gives us the foundation and the frame work for doing improvement work. It is structured around several key components. There are 3 questions that are presented on this model. First question is what is your aim? We have also ask ourselves how good we want to be and by when we will like to achieve it. Second question is how would you know a change is an improvement? Which gets to measurements, we want to look at process and outcome measures. The third question is what changes can we put in place to achieve the aim? What change we can put into place that you can tract with data and you can match back up against your aim (Lloyd, 2009).

The purpose of this paper is to analyze the unfortunate sentinel event of Mr. B, a sixty-seven-year-old patient presenting with severe left leg pain at the emergency room. A root cause analysis is necessary to investigate the causative factors that led to the sentinel event. The errors or hazards in care in the Mr. B scenario will be identified. Change theory will be utilized to develop an appropriate improvement plan to decrease the likelihood of a reoccurrence of the outcome of the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will be used to project the likelihood that the suggested improvement plan would not fail. Lastly, key roles nurses would play in improving the quality of care

As we know that, leadership is nothing. But the influencing flowers. Leadership includes three fundamental clusters of skills creating vision, garnering commitment to that vision, an managing progress toward the realization of that vision. powerful and effective leaders plays very vital role to reach the maximum production for any organization.

The change models discussed in class provide a pattern for change and presents a picture of what will occur

The model encourages the person to think systematically about and experience or activity and allows the opportunity to recognise areas that can be improved upon or developed. The model takes the form of a cycle, which uses a six step approach covering a description, feelings, analysis, evaluation, conclusion and finally action plan. My choice of model, over Johns (2000) model for example, was due to its clear structured cycle which allows the opportunity to renter a stage in order to try and improve upon a situation. Where as Johns (2000) model, does not allow this opportunity although it is a useful model as a guide for analysis of a critical incident. Although, I will have to develop the model to ensure that I critically analyse in order for it be of a higher standard at this stage of the training.

Activity 3 looked at McWhinney’s Model of Change (1997), how it could be utilised to solve complex problems and how it can be related to the model.