OrgSystemsTask2-Template.pdf

TITLE OF PAPER 1

Organizational Systems and Quality Leadership

Task 2

Your Name (without letters or titles)

TITLE OF PAPER 2
Organizational Systems and Quality Leadership Task 2

A. Root Cause Analysis

The task directions for this prompt are to complete a root cause analysis that takes into

consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s

outcome). Review the IHI content on root cause analysis before beginning this task so that you

are sure you understand the process. Then, simply follow the steps in the process. While cause

and effect and Ishikawa diagrams are visual representations of the relationships between the

causative factors, their use is not mandatory in this assignment. It is better, generally, to describe

in essay form what factors are involved, and how they are related.

You will also want to clearly identify any errors (causative factors) and/or hazards

(contributing factors) in the scenario. List these, together with an explanation of why you

identified them as errors or hazards. I strongly encourage you to be very specific in which factors

you are identifying as errors, and which as hazards. You might consider separating each into its

own paragraph in your response.

B. Improvement Plan

The task directions for this ask you to discuss a process improvement plan that would

decrease the likelihood of a reoccurrence of the outcome of the scenario. Think about this paper

as describing an ongoing cycle of activities surrounding the sentinel event. In the RCA you

identify the causes of the problem, in this section you are offering a plan to correct those causes,

and in the third section you will evaluate your plan to determine whether it will do what you

intend it to do.

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In this prompt you are describing the changes in the process of care for conscious

sedation that you recommend to address the causative factors you identified in your RCA. What

specific changes do you recommend to prevent a recurrence?

B1. Change Theory

In this prompt you are to discuss a change theory that could be used to implement the

process improvement plan developed in B. You will want to review the material in IHI on

change theory (QI 105) so that you understand what it is, and how it is used. Pay careful

attention that you are both describing the change theory, and applying it to your plan of

correction. You will want to identify the theory you are using, describe each of the steps or stage

of that theory, then describe how each of the stages will be applied to your improvement plan.

Students have a tendency to describe one or the other, but to then forget to combine the two into

a coherent approach to implementing their plan of correction. After you’ve written this section,

be sure to go back and make sure that you have tied the concepts together.

C. FMEA

The task directions for this prompt are to use a failure mode and effects analysis (FMEA)

to project the likelihood that the process improvement plan you suggest would not fail. This

prompt contains four sub-prompts (C1, C2, C3, and C4). These prompts are part of your

response to C. Do not get confused or feel that you are repeating yourself. You are simply being

guided through the process of answering this general prompt.

In this prompt, describe what the FMEA is, then provide substantial support to imagine

how your plan would be successful and how you would use the FMEA to determine that it would

be successful (or would not fail.) You do not need to actually implement the FMEA, you only

need to describe how you implement it.

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C1. Members of the Interdisciplinary Team

The task directions for this prompt merely ask you to identify the members of the

interdisciplinary FMEA team. A mere listing is probably insufficient; you will want to provide

some justification for your choices.

C2. Pre-Steps

The task directions are to discuss the steps in preparing for the FMEA. Be sure you

address your improvement plan in your discussion. This prompt challenges students because the

steps are not spelled out. Consider that virtually all procedures involve a series of steps that can

be divided into three phases: steps in preparing for the process, the process, and the post-steps. A

careful reading of the steps of the FMEA, as outlined in the FMEA tool available from the IHI

website, will reveal the three phases of the process. That is, the steps that occur before the actual

FMEA begins, the analysis process itself, and the steps that follow the analysis. To properly

answer the prompt, I would suggest clearly identifying the steps, then describing them. That is,

“Step one is yadda, yadda, yadda.” This way the evaluator can easily identify the steps you are

discussing.

C3. Three Steps

The task directions for this prompt are to apply the three steps of the FMEA (Severity,

occurrence, and detection) to the process improvement plan you created in prompt B. Again,

insure that you are clearly identifying each of the three topics and that you are applying them to

the scenario. I strongly suggest that you discuss each in its own paragraph and not intermingle

them. Intermingling them leads to a confused discussion and may make it difficult for the

evaluator to clearly identify the three elements. Be sure to describe how each is used in the

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FMEA process. A thorough discussion will include a description of the three steps, a description

of how they might be applied to your improvement plan, and a discussion of the purpose and

application of RPN values.

Remember that you do not have to carry out the FMEA. This means that you do not need

to develop tables, assign numbers, and so forth. You merely need to describe the processes

involved.

C4. Interventions

The task directions for this prompt are to explain how you would test the interventions from the

process improvement plan from part B to improve care in a similar situation. You want to be

very specific in describing how you might test your improvement plan.

D. Key Role of Nurses

The task instructions for this prompt are to discuss how the professional nurse may

function as a leader in promoting quality care and influencing quality improvement activities.

This prompt may be a more generic discussion of how nurses function as leaders in improving

quality of care. Think about some of the things that you have learned in this course about the role

that nurses play in influencing quality in healthcare. Review the IHI material and your Cherry

and Jacob text for additional ideas. Discuss WHY the nurse plays a key role. You might consider

some of the provisions from the ANA Code of Ethics (or those of other professional nursing

organizations).

The Reference Page

The Reference Page always starts on a new page, never at the tail end of the final

paragraph. Use the hard page command to force a new page – [Ctrl]-[Enter]. The Reference

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Page uses hanging indents: this document is set up with a hanging indent on the Reference Page

if you choose to use it as a template. Sources are listed alphabetically by first author’s last name

or by organization if no author can be found. The title of the article is in sentence case, not title

case, and is italicized. The Online Writing Lab at Purdue is an excellent source for guidance on

citations and referencing. Simply use an internet search engine to find “OWL at Purdue APA

format”. Do not allow any blue underlined hyperlink to remain when typing in a Web link. As

soon as it automatically appears, immediately backspace once to remove it.

Referencing Your Citations

This is a good rule of thumb – If the thought didn’t originate within your cranium, it

originated within someone else’s cranium, and therefore must be cited (this includes anything

paraphrased or quoted). If it is cited, it must be listed on the Reference page. If it is not cited, it

should NOT appear on the Reference page. Hint: anything you looked up or read on the internet

did not originate within your cranium ☺ and that includes state regulations, the ANA Code of

Ethics, IHI modules, course textbooks and online courses, etc.

Sources. If you use sources, include all in-text citations and references in APA format. When

using sources to support ideas and elements in a paper or project, the submission MUST include

APA formatted in-text citations with a corresponding reference list for any direct quotes or

paraphrasing. It is not necessary to list sources that were consulted if they have not been quoted

or paraphrased in the text of the paper or project. Note: No more than a combined total of 30%

of a submission can be directly quoted or closely paraphrased from sources, even if cited

correctly. For tips on using APA style, please refer to the APA Handout web link included in the

APA Guidelines section. Remember: Personal correspondence and interviews should NOT be

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listed on the reference page, because they are not discoverable for anyone else; but they may be

cited within the document.

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References

Authors, R. & Alphabetic, O. (2010). Authors must be in alphabetic order. Search Owl at Purdue

for APA Style Helps. http://owl.english.purdue.edu/. (try not to allow blue hyperlinks).

Any hyperlinks on the reference page must work – the evaluators WILL check these. Do

not hyperlink to a page within an area accessible only through personal login, because the

evaluator does not have your login and password.

Hope-this-helps, I. (2013). Use this document to create your own template: Fill in your own

information. Mentoring Advice Times: 7, 1-3.

Last, N. & First, I. (1998). Title in italics without caps. Town, ST: Lippincott.