NUR45200 Assignment 3-Construction of Root Cause Analysis

NUR45200 Assignment 3-Construction of Root Cause Analysis

Subject: General Questions    / General General Questions
Question

1. Find and choose a process to improve related to a healthcare organization or patient safety issue. (Please consult the No Topic List in Resources as you cannot choose any of those topics.) Your problem must be either:

A quality/patient safety issue such as reducing one of the Harms or a problem seen in your own clinical nursing practice that reduces quality and safe patient care. You may want to choose a problem that you can try to improve in your own practice rather than something that will require that other staff will need to do. Of course, you cannot use and copy the RCA examples shown in the textbook, additional readings and websites, student samples, podcasts/videos, or IHI lessons nor those on the No Topic List.

Remember the rule: Do not identify the organization and its location and people involved!

Construct a Cause and Effect/Fishbone diagram – Root Cause Analysis (RCA).

The goal is to determine the human and other factors most directly associated with the incident, event, or close call and the processes and systems related to its occurrence (there is rarely only one underlying cause).

You must show a minimum of 4 categories/factors and no more than 7 categories/factors (4 to 7 main fish bone branches). You need to choose these wisely so they fit your problem. Here are some category examples for your RCA*:

patient factors

communication factors

staff factors ( i.e., such as knowledge, skills, competence, performance, noncompliance, etc.)

work environment

equipment factors

process which include policies, procedures ,and guidelines

technology

organizational culture

uncontrollable external factors that organization cannot control, i.e. natural disasters

Or you might consider using classic organization category headings:

4 M’s — Man, Machine, Material, Methods

6 M’s — Machine, Method, Materials, Man, Measurement, Mother Nature

4 P’s — People, Place/Plant, Policies, Procedures

8 P’s — Price, Promotion, People, Processes, Place/Plant, Policies, Procedures, Product

4 S’s — Surroundings, Suppliers, Systems, Skills

6 X’s — Equipment, Process, People, Materials, Environment, Management

4 I’s — System, Sub-system, and Component Interfaces:

Spatial (physically touching), Energy (transfer),

Information (exchange), Material (exchange)

5 Pd’s — P-diagram design robustness noises:

Piece-to-piece, Customer usage and duty cycle, Degradation over time,

Environment, Interactions with other systems (4I’s)

*Please refer to the textbook, IHI Open school lessons, and review of websites for a variety of categories/factors to label the main fish bones.

c. Once you have the categories labeled on the branches, start to fill in any possible causes on the horizontal lines coming from each branch. (In the three templates provided, these causes are textboxes, you need to click on the cause and retype over it. If you are unfamiliar with textboxes, you will need to refer to Microsoft Help or Google on how to type in textboxes). Fill in anything that could possibly have an influence on the issue. This is not the time to decide if an idea is good or not, just brainstorm to collect any possible causes. Do not insert solutions but causes! You need to have at least 3 appropriate causes under each category/factor. Your clinical experience and knowledge will help you with determining the causes. You may need to review the literature related to the chosen problem.

d. Then, mentally evaluate each of the causes on each branch of the fishbone diagram individually and in more depth. You want to determine what the impact is of the cause and if that cause leads to the effect or problem. You also need to determine what the impact is if changing the cause could lead to the solution of the effect or problem you are investigating. Do this for each branch and all causes. At this point, you may want to remove it or leave it. This mental evaluation is a critical thinking exercise which provides you the opportunity to “double check” that these are true causes. You need to do this before you start thinking about and writing a solution (this you will do for Module 4 assignment). Do not add this mental exercise component to the RCA nor submit it as a narrative.

e.Templates*: Use may use the following templates found in the Resources:Fishbone 4 categories; Fishbone 6 categories;Fishbone 7 categories;

OR

You can use the draw tools in Microsoft Word or you may hand-draw the fishbone diagram. You must scan your computer drawn or hand drawn RCA and submit as a word doc, pdf, or jpeg.

*All RCAs must be neat, legible, and readable that demonstrates college level work. Sloppy, messy, etc., RCAs will earn a grade of Zero (0).

Do not use other RCA template software programs. Your coach will not have access to the variety of RCA template software programs available.

Submit to the Assignment 3 Blackboard submission area by end of day, Sunday of Module 3.