General Purpose Of Conducting A Root Cause Analysis Process
A. The general purpose of conducting a root cause analysis.
“The key to solving a problem is to first truly understand it.” (Ask "Why" Five Times to Get to the Root Cause, 2017) Root cause analysis is a phrase that describes a wide range of methods, tools, and techniques used to investigate deeper and uncover the cause of a problem.
A1. The six steps used to conduct an RCA, as defined by the Institute for Healthcare Improvement (IHI)
Step 1: “Identify what happened”. (Patient Safety 104, 2017) This step will describe what happened in the event. It will be depicted correctly and in its entirety to be able to organize and clarify evidence about the event.
Step 2: “Determine what should have happened”. (Patient Safety 104, 2017) This step is …show more content…
Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan.
Kurt Lewin’s most influential theory was The Change Theory. He theorized changes in prior leaning to be rejected and replaced in a three-stage model known as unfreezing, change- and refreeze. (Change Theory Kurt Lewin, 2017)
The first step in the process of letting go of an old pattern is unfreezing. In this step it is necessary to understand why the process does not work and the need for a new process. In the scenario the understanding of the sentinel event and how the procedures lead to the event, therefore the need for new procedures. The addition of new staffing guidelines and safety procedures in sedation of patients. The need for additional nurses in the ER with a higher nurse to patient ratio. Also a new procedure of safety steps in sedation.
The change state is the second step which is also called "moving to a new level". (Change Theory Kurt Lewin, 2017) This step of the process of change involves a change in thoughts, feeling, behavior, or all three, that is more productive. (Change Theory Kurt Lewin, 2017) In this step the staff would implement the new guidelines and procedures. The management will be available to oversee the new changes in action. This would include more nurses in the ER as the patient load increased. And to oversee the new guidelines on sedation for patients was being utilized
“The key to solving a problem is to first truly understand it.” (Ask "Why" Five Times to Get to the Root Cause, 2017) Root cause analysis is a phrase that describes a wide range of methods, tools, and techniques used to investigate deeper and uncover the cause of a problem.
A1. The six steps used to conduct an RCA, as defined by the Institute for Healthcare Improvement (IHI)
Step 1: “Identify what happened”. (Patient Safety 104, 2017) This step will describe what happened in the event. It will be depicted correctly and in its entirety to be able to organize and clarify evidence about the event.
Step 2: “Determine what should have happened”. (Patient Safety 104, 2017) This step is …show more content…
Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan.
Kurt Lewin’s most influential theory was The Change Theory. He theorized changes in prior leaning to be rejected and replaced in a three-stage model known as unfreezing, change- and refreeze. (Change Theory Kurt Lewin, 2017)
The first step in the process of letting go of an old pattern is unfreezing. In this step it is necessary to understand why the process does not work and the need for a new process. In the scenario the understanding of the sentinel event and how the procedures lead to the event, therefore the need for new procedures. The addition of new staffing guidelines and safety procedures in sedation of patients. The need for additional nurses in the ER with a higher nurse to patient ratio. Also a new procedure of safety steps in sedation.
The change state is the second step which is also called "moving to a new level". (Change Theory Kurt Lewin, 2017) This step of the process of change involves a change in thoughts, feeling, behavior, or all three, that is more productive. (Change Theory Kurt Lewin, 2017) In this step the staff would implement the new guidelines and procedures. The management will be available to oversee the new changes in action. This would include more nurses in the ER as the patient load increased. And to oversee the new guidelines on sedation for patients was being utilized