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Organizational Systems & Quality Leadership
Introduction
The core objective of health care is to provide high-quality care to all patients to guarantee positive health outcomes. This principle is a major driver for the commitment of nurses and other care providers. Care providers are required to work in collaboration and include patients in the process of care. Nurses form the core of health care delivery in all facilities. The role they play in the coordination of care is essential for the professionalism of care providers. In the process of care delivery, it is important to understand the medical history of the patient to determine the most appropriate interventions to employ. Care providers should employ interventions that are besides guaranteeing positive health outcomes address the needs and interests of the patient. It is important to include family members in the treatment program since they understand the patient and his needs better. This paper employs Root Cause Analysis approach together with the Failure Mode and Effect Analysis to determine the impact of the events that resulted in the death of a patient Mr. B.
A. Root cause analysis
The principal purpose of the Root Cause Analysis is to conduct an evaluation of the highest level of the problem to identify the actual cause. In the case scenario, the root cause analysis rules out the possibility of inadequate patient assessment as a contributor to the factors that resulted in the death of the patient (Andersen, Fagerhaug & Beltz, 2009). The patient arrived at the facility complaining of severe pain in the hip region and the left leg. The nurse in charge conducted a routine check for vital signs including blood pressure, weight, and heart rate. Most of the patient's vital signs were normal indicating that he did not have a life-threatening complication. The medications that the patient had been administered with previously were also noted. This shows that a comprehensive assessment of the patient's health condition including medical history, symptoms, and current medications was done. Therefore, the factors that lead to the negative outcomes did not happen at the assessment stage. RCA presumes that all medical systems are interconnected and that any activity in the process of care delivery can trigger a series of events (Andersen, Fagerhaug & Beltz, 2009). Therefore, the actual cause of a specific problem can be traced either forwards or backward. Human, organizational and physical causes may have contributed to the eventuality of Mr. B. For instance, when the oxygen saturation alarm went off denoting that PO2 was decreasing the nurse simply ignored the right protocol and reset the alarm. A decline in oxygen concentration may have led to the death of the patient. Organizational factors come in whereby despite there being several backup staff, nurse J left Mr. B unattended and started attending to other patients.
Plan to decrease reoccurrence of the outcome
A risk management plan should be developed to decrease similar outcomes in the future. The risk assessment plan includes measures for facilitating close monitoring of the patients vital signs. Data obtained from the monitoring system would then be used to determine whether the patient is making positive progress concerning the treatment plan. All deviations from normal should be noted regardless of their magnitude since if deviations are left unattended they might lead to critical health challenges. Regular reports of the patients' progress should be presented to the treating physician and the nurse in charge. The risk assessment plan requires nurses to adhere to physicians orders. Deviations from the directive of the physician should be noted and addressed practically to avoid subjecting the patient to unnecessary health challenges. This plan should include a chain of command, which should be followed. The nurse in charge should be notified of all problems that arise during care delivery (Cameron & Green, 2012). Only nurses who are trained on a specific area should be involved in patient care in that department. Nurses who are not conversant with a particular area should work under close supervision of the nurse in charge. All medical errors need to be reported appropriately and immediate correction plans initiated (Cameron & Green, 2012). It is important to ensure that patients are not left unattended, especially after critical procedures have been conducted.
Failure Mode and Effects Analysis
Failure Mode and Effects Analysis (FEMA) is essential for identifying some of the possible causes of failure in a system. FEMA comprises of an assessment of the actual impact of the failure (Stamatis, 2003). The failure of a particular system is categorized according to the intensity of the consequences and the ease of detection together with the rate of occurrence (Stamatis, 2003). In the case study, all aspects leading to the nurse’s action should be analyzed to minimize cases of putting the lives of other patients at risk. A change model needs to be adapted to transform positively the behavior of nurses and minimize cases of patient neglect.
A Change Theory That Could Be Used To Implement the Process Improvement Plan Developed
Kurt Lewin Change Management Model is the most appropriate change theory to employ in this scenario. This model has three phases, which can easily be integrated into the health care system. Unfreezing is the first phase, and it includes preparing all the relevant entities for the proposed change (Demers, 2007). Care providers can understand the benefits of change and embrace it. The transition is the second phase and comprises of making practical changes related to traditional operation modalities. This is the phase where the mentality of care providers is changed, and all parties are made to become accustomed to the new organizational framework (Demers, 2007). The change process can be facilitated using role models. In this case, the role of experienced nurses in training the juniors comes in handy. Refreezing is the final stage of the model and it involves establishing stability following change implementation (Demers, 2007).
An organizational culture change based on Kurt Lewin model should be initiated to ensure that similar scenarios do not occur in future. The nurse in charge should facilitate the development of an environment where all junior nurses take a proactive role in the management of patients' issues. Training programs should also be established to guide care providers on the ways to achieve positive outcomes in different health care activities. The mentality of care providers that a particular task is the responsibility of another person should be eliminated. For instance, in the case scenario, the LN could have realized that it was her responsibility to report changes in vital signs of the patient immediately rather than waiting for the problems to be detected by someone else.
Members of the FMEA
For the FMEA to achieve the intended objectives, members should be experienced and highly competent. Some of the parties who should be included in the FMEA team are health care leaders, nurse leaders, physicians, and risk management planners. Nurses are crucial members of the team since they are directly involved in patient care. Family members may also be included to provide the social and psychological support necessary for enhanced patient recovery.
Pre-steps of the FMEA
The major steps in preparing for FMEA include constituting a team of professionals who can effectively handle issues related to patient health. The information obtained from the professionals should be used to develop a concrete risk management plan. Medical processes that increase the risk of negative outcomes should be identified and addressed in the management plan (Stamatis, 2003). The other step involves identification of failure modes and their adverse outcomes. A root cause analysis should be carried out as a means of identifying the real causes of certain problems. To make sure that the expected outcomes of the FMEA are achieved, through various development phases, an examination of past failures together with the preparatory document should be carried out. The main activities carried out in the preparatory stage are failure mode development, and development of parameter and process flow diagrams. The purpose of these pre-steps is to identify potential causes of interfaces, the environment, and surrogate products. During a failure, mode development rules, and regulations of nursing practice are identified, together with desired outcomes.
Application of the three steps of the FMEA (severity, occurrence, and detection)
The key factors that may lead to negative consequences should be looked for in all medical procedures.
Severity:
The severity of every outcome will be analyzed for every failure mode. An analysis of the severity level is crucial in health care as it helps in determining the real effects of different situations. This makes it easy to prioritize factors that are essential for positive health outcomes (Stamatis, 2003). The end effect of various negative actions will be given values from I (no effect) II (very minor damage), III (minor/low damage), IV (moderate damage), V (critical damage and loss of safety margins), to VI (catastrophic including loss of life). These values will also act as indicators of the quality of life given to patients.
Occurrence:
It is also important to select an occurrence level for every effect following the identification of possible causes of failure. This makes it easier to analyze the frequency of specific problems and their effects on the patients.
Detection
Practical control measures will be identified and implemented to ensure that the risk management plan is efficient. Detection identifies the existing controls that can minimize the occurrence of a particular scenario. The probability of a problem happening needs to be detced and acted upon before it occurs.
Testing the interventions from the process improvement plan to improve care
A test for the efficiency proposed interventions can be done using the Plan-Do-Study-Act (PDSA) cycle. This cycle is suitable for almost all improvement plans. The cycle includes planning for change, implementing the change, and observing the results. Observation helps detect whether the change is bringing about the anticipated improvement of care. The check and act stages of the cycle are most important especially in health care scenario, since besides identifying possible risk factors they raise the need to take on necessary corrective measures. The PDSA cycle requires nurses to act as managers in all stage of change implementation. The PDSA cycle will be incorporated in all stages of care delivery. Under PDSA, the expected findings are documented and data analysis conducted. The relevance of assessment procedures upon presentation of a patient will be done. This will help ensure that concrete patient information is obtained. Other aspects of care that shall be analyzed in the PDSA cycle include the coordination of care providers, the quality of care provided to the patient from the initial point of contact, dispute resolution strategies adopted, and the role played by family members (Cameron & Green, 2012). The time was taken to provide crucial care to the patient should also be noted. The manner in which nurses conduct themselves during delivery of care should be evaluated. Information obtained from this analysis will be used in developing a plan of action. This information will assist in determining the actual areas that require changes.
Functions of a Professional Nurse Leader in Promoting Quality Care
Nurse leaders play a crucial role in the process of care delivery. They oversee the implementation of mechanisms aimed at creating a safe environment as well as a culture that guarantee quality health care delivery (Edmonson, 2010). Nurse leaders have a legal an ethical responsibility to use their voice to ensure that nurses engage in actions that eliminate moral distress among nurses. They also have a responsibility to handle conflicts that can increase the health risk of patients (Edmonson, 2010).
Conclusion
The role of nurses in health care delivery is crucial for the attainment of better health among patients. The process of care delivery should be evaluated comprehensively to detect pointed to adverse health risks. A risk management plan should be developed to address all health care risks. Family members should be involved in the process of care to provide patients with social and psychological support.

References
Andersen, B., Fagerhaug, T., & Beltz, M. (2009). Root Cause Analysis and Improvement in the Healthcare Sector: A Step-by-step Guide. New York, NY: ASQ Quality Press.
Cameron, E., & Green, M. (2012). Making Sense of Change Management: A Complete Guide to the Models Tools and Techniques of Organizational Change. Sudbury, MA: Kogan Page Publisher.
Demers, C., (2007). Organizational Change Theories: A Synthesis. New York, NY: SAGE
Edmonson, C. (2010). Moral Courage and the Nurse Leader. Retrieved on November 07, 2015 from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Courage-and-Distress/Moral-Courage-for-Nurse-Leaders.html
Stamatis, D.H., (2003). Failure Mode and Effect Analysis: FMEA from Theory to Execution. New York, NY: ASQ Quality Press.