Organizational Systems And Quality Leadership, Root Cause Analysis - C489 Wgu

2147 words - 9 pages

Organizational Systems and Quality Leadership

A. Root cause analysis, RCA is used to determine the cause of events, sentinel events and near misses in healthcare and how to react to prevent re-occurrence of the issue. Many hospitals, offices and other healthcare facilities around the world use this method.

A1. 1. Identify what happened?
The team must describe the event to organize information about the event. Some teams create a flowchart of the information leading up to the event. It allows an organized picture of what happened in order leading to the event. (Patient Safety 104: Root Cause and Systems Analysis.)

2. Determine what should have happened?
The team has to identify what should have happened in an ideal event. Some teams find it useful to complete a flowchart of how things should have been done and compare it to the flow chart created in step 1. (Patient Safety 104: Root Cause and Systems Analysis.)

3. Determine the cause
This is where the team determines the contributing factors to this event. They look at direct causes of the event which are the more obvious issues. Then they look at contributing factors that are indirect in nature. It is also useful for the team to ask "why" five times to get down to the root cause of the incident. Some teams also find it useful to use the fishbone diagram to investigate and connect possible causes of certain events. (Patient Safety 104: Root Cause and Systems Analysis.)

4. Develop a casual statement
A causal statement correlates the cause to its effects and then back to the main event that prompted the root cause analysis in the first place. A casual statement explains how facts/factors about current conditions contribute to bad outcomes for patients and staff. A casual statement has three parts; the cause, the effect, and the event. (Patient Safety 104: Root Cause and Systems Analysis.)

5. Generate a list of recommended actions to prevent reoccurrence
Recommended actions refer to changes which the Root cause analysis team hopes will assist in preventing the event under review from recurring. (Patient Safety 104: Root Cause and Systems Analysis.) Recommendations may fall under the following groups;
Improving or updating the software
Standardizing equipment
Employing forcing functions which physically hinder users from making recurrent errors
Ensuring redundancy, for instance using backup systems or double checks
Establishing new policies
Simplifying the process
Training the staff
Applying cognitive aids, for example, mnemonic devices

6. Prepare a summary and share it.
This is a chance to engage with other members of the group to create the next steps in the process. Some groups use flowcharts for this as well to keep information in an organized fashion.

A2. From this scenario, Mr. B passed away 7 days after his event occurred. Mr. B passed away from complications of sedation that led to cardiopulmonary arrest. One of the main causative fact...

More like Organizational Systems And Quality Leadership, Root Cause Analysis - C489 Wgu

Organizational Systems And Quality Leadership - WGU C489

414 words - 2 pages ... Organizational Systems and Quality Leadership Task 1 A. Understanding of Nursing Quality Indicators Nursing quality indicators are factors that are shown to be directly affected by nursing. The use of restraints and pressure ulcers are two major nursing quality indicators. Religion plays a very important role in most patient care that is provided. Understanding the patient's religion could help nurses determine why the patient was agitated ...

Organizational Systems And Quality Leadership - WGU C489 - Essay

1435 words - 6 pages ... C489 – TASK 3 Organizational Skills and Quality Leadership Western Governor’s University Cesar Vega Student ID: #000680503 November 10, 2018 A1. Country to Compare The country whose healthcare system I am comparing to the United States is Japan. A2. Access Healthcare access in Japan consists of two major type of insurance: National Health Insurance (NHI), or Employees’ Health Insurance through an individual’s place of employment. NHI is ...

Organizational Systems And Quality Leadership Task 1 - WGU Organizational Systems And Quality Leadership Task 1 - Assignment

829 words - 4 pages ... Running head: Organizational Systems Task 1 1 Organizational Systems and Quality Leadership Task 1 Cecilia Koutoubi Western Governors University Organizational Systems and Quality Leadership Task 1 A. Understanding of Nursing Quality Indicators A.In 1998, American Nurses Association established a database program where healthcare organizations can input and measure their efficacity and safety in nursing care. This is called National ...

Organizational Systems - WGU C489 - Research Paper

1974 words - 8 pages ... RCA and FEMA 9 Organizational Systems and Quality Leadership Task 2; SAT1-1217 Organizational Systems and Quality Leadership Task 2; SAT1-1217 A. Root Cause Analysis Root cause analysis (RCA) is a consistence procedure which is used for determining root causes of events or issues and an approach for reacting to them ...

Task 1 Nursing Quality Indicators - Organizational Systems And Quality Leadership - Essay

1110 words - 5 pages ... Task 1 Organizational Systems and Quality Leadership Applying nursing-quality indicators has been intended to focus on plans and programs to increase quality and safety in patient care by identifying issues that may interfere with patient care. In the scenario provided by Mr. J, nursing-sensitive indicators are analyzed for an understanding of the issues that interfere with patient care. Some commonly used nursing-sensitive indicators are ...

Nursing Quality Indicators Assignment - Wgu C489 - Assignment

685 words - 3 pages ... Running head: Organizational Systems Task 1 2 Organizational Systems and Quality Leadership Task 1 Chaniece Vasquez Western Governors University A. Understanding of Nursing Quality Indicators Nursing-sensitive indicators identify structures of care and care processes, both of which in turn influence care outcomes (Montalvo, 2007). The indicators reflect nursing and the impacts it has on patient care. The mission behind this is to help ...

Organizational Development Task 1 - Wgu C489 - Essay

1170 words - 5 pages ... that care is measured is by the nursing quality indicators. if we can track each hospitals performance with those indicators, we can see what areas are in need of improvement and where we are excelling. B-in situations like the one we are studying we must look at the overall performance of the specific hospital. We are able to track this data by monitoring nursing quality indicators. Nursing quality indicators are protocols driven by best practice ...

C200 Task 1 Organization And Leadership Analysis - WGU - Performance Assessment

5931 words - 24 pages ... leadership, he is progressively transforming each member into this same image. The CO and the department's culture are one in the same as it stands now. SWOT Analysis B1. Organizational Strengths One of the biggest strengths that this department has is that there are 50 active firefighters that are on-call 24/7/365 days out of the year, spread across the entire city limit. This is a really big deal for the department as well as the community. Each year ...

Organizational Ethical Analysis Paper - Ethical Leadership - Essay

2296 words - 10 pages ... Running head: ORGANIZATIONAL ETHICAL ANALYSIS PAPER 1 ORGANIZATIONAL ETHICAL ANALYSIS PAPER 9 Organizational Ethical Analysis Paper Alexandr Khlyzov Western Kentucky University Overview Steve Jobs and his friend, Steve Wozniak were the main people behind the startup of Apple Company. In fact, those two friends were talented, smart and very creative which they both dropped out of high school and they both started working for Hewlett Packard ...

Use And Develop Systems That Promote Communication - Leadership In Health And Social Care Level 5 - Assignment

1857 words - 8 pages ... Leadership in health and social care, level 5. Unit 1 Assignment: Use and develop systems that promote communication. 1.1 Review the range of groups and individuals whose communication needs must be addressed in own job role. I work directly with service users, families and relatives, employer and colleagues. I work indirectly with other health care professionals and external agencies to provide the care that service user’s needs. Therefore, a ...

Rose Company Case: Maintaining Competitive Leadership And Gaining Product Advantage - University Of Massachusetts - Managing Organizational Change

1308 words - 6 pages ... Situational Analysis To open our meeting, could I recap some of the details on how management came to the decisions regarding the Jackson plant, and my appointment as General manager so that I can verify my understanding of the situation. As technology and competitors have advanced in our industry, the need to address the poor operational performance at the Jackson plant, which has been unsatisfactory for several years, product quality is down ...

The Scaffold Plank Case: An Analysis Of Effectiveness In An Organization - Eastern/ Organizational Theory And Design - Case Analysis

1859 words - 8 pages ... Parrish’s goal is to get lumbar for a customer and land their account in the cheapest and quickest way possible. b. Systems Theory: The subsystems in this case are the different companies (White Lumbar and Quality Lumber). The different jobs, trader, buyer, owner/manager, bookkeeper, and forklift operator. c. Multiple Constituency Theory: The constituencies in this case are White Lumber Company, Quality Lumber Company, Quality Lumber’s customer, White ...

Simulation Analysis, Leadership And Ethic Issues About Everest Simulation Group Work. - MGTS1301 - Essay

1180 words - 5 pages ... teamwork. We should combine the theoretical knowledge of leadership and ethical analysis of the actual situation and make better decisions. Leadership Description of Issue While simulating the game of climbing Mount Everest, the team leader actively communicated with the team members and consulted the opinions of the team members. However, when the task structure was measured, there was no apparent conflict between our tasks and personal goals. It ...

Year 11 Economic Analysis Of China And Australia, Including Economic Growth, Employment And Unemployment, Quality Of Life And Role Of Government

2267 words - 10 pages ... negative.Findings from this study underscore the environmental concerns of the Chinese leadership:· Each year, an estimated 178,000 Chinese in major cities suffer premature deaths because of atmospheric pollution in excess of standards. Also, acid rain from high sulfur regions heavily damages the environment each year to crops and forests· Water pollution, a major focal point of recent Chinese policy, has contaminated 52 of 135 ...

Professional Leadership And Communication Task 1-bioreactions - WGU C820 - Essay

1270 words - 6 pages ... Professional Leadership and Communications for Healthcare C820 Task 1 Bio-Reactions Western Governors University A. Freeze: The bio-reaction I experienced in this story is Freeze. I have always been terrified of flying and usually flew with my husband who I could hold onto and squeeze when I became scared. Years ago I flew alone for the first time to WA to surprise my mom for Mother’s Day. I sat on the aisle seat next to two young guys who were ...