This is a Collaborative Learning Community (CLC) assignment. Write a 750-1,000 w

Question

This is a Collaborative Learning Community (CLC) assignment.

Write a 750-1,000 word paper that explains the root cause analysis process that the health care organization would use and perform a root cause analysis. Quality improvement requires multiple perspectives to identify root causes and develop optimal solutions for success. Root cause analysis is most effective when performed collaboratively.

As a team, select a health care organization that is currently having a severe adverse occurrence reported. Select an area within your organization to perform a root cause analysis that includes but is not limited to the following:

Topic Chosen: Recent UCLA Security breaches

Prior to creating the root cause analysis consider the following in a collaborative setting that allows for dialogue.

1. What are the major root causes and the impact of the adverse occurrence?

2. Which stakeholders are relevant to your adverse effect? Why?

3. What information is needed to perform a root cause analysis?

4. Which tool would you use to create a root cause analysis? Why?

After the root cause analysis is complete address the following questions:

1. What other kinds of information would be helpful? Why?

2. What approach did the team take?

3. What information did you use in your root cause analysis?

Be sure to address all of the previous questions posed above in the paper in order to explain the root cause analysis process. Include the root cause analysis as an appendix.

Include three to five references, to in your analysis.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

Explanation / Answer

patient’s life can be saved or destroyed by the health care system. This mostly depends on the efficiency of the health care system in use which is a major reason behind every patient’s safety. A root cause analysis comes in handy to understnand where the system is failing and the areas which need improvement there by increasing the chances of absolute safety of every patient.

All health care organisations experience problems of varying magnitude but this comes as a big blow only when a patient id adversely affected due to the underlying problems in that particular health care system. It is to be noted that the errors in health care have grown substantially over the last few years. However, there is not strong evidence that proves or puts the blame on a single reason. One of the reasons for high number of errors in health care systems is due to the absence of a standardized nomenclature.

. It is also to be noted that in a study conducted on 815 patients in a university hospital, it was found that 36 percent were declared ill as a result of continuous therapy, which

Could also lead to some form of disability in the future. In an other study conducted on 1047 patients at a large teaching hospital, 45 percent of the patients were identified as having had an adverse effect, in this case the adverse affect leading to producing disablity or death.

The following are the major root causes why errors have taken place in health care system over the past one decade

Post surgical Complication:

Anesthesia

Inadequate follow up after treatment

Missed or delayed diagnosis

Failure to act on Test results

Hospital acquired infections

Incident Reporting Tools

Medication Related errors

Medication errors in Hospitals

Medication errors in ambulatory settings

Tools used to create a Root Cause Analysis:

Lean Six Sigma : A methodology that is a result of team effort which helps in improving the performance by eliminating wastage

Brainstorming technique : This technique is very popular where a group of people put in their efforts to find a conclusion for a specific problem by gathering a list of ideas.

Change Analysis : This is a six step process that describes the problem, then describes the same situation without the problem , compares the situations and identifies the result of the differences

Change Management: This is a structured approach where individuals are moved from their current job or role to a new form of role

Control Chart: This is a graph used to study how a process changes over time. Here, a central line for average, an upper line and a lower control line are plotted in a chronological order

Flow chart

Kaizen: This is a Japanese business philosophy where continuous improvement is strived by following various Kaizen techniques

Stakeholder Analysis

Standard Work

Value Stream Mapping

The following information is required to successfully conduct a RCA:

Patient’s information: Patient’s previous history is important to determine the resistance system which differs from one patient to another patient. It is important for the Facility center to understand the list of medication which was used by the patient before undergoing any instense medical treatment

Medical devices / equipment: The standard or level of medical devices which are used over a patient’s body have to be understood thoroughly before going ahead with a root cause analysis of any mishap.

Patient treatment/ procedure: The treatment/ procedure differs from patient to patient and mostly lies on the intensity of the problem at hand. A complete understanding of the procedure helps in eliminating any unwanted guessing at the RCA level

Risk management level of the health care system

Human factors and patient safety culture: Human factors like a tired nurse is one of the major human factors which might affect the productivity and efficiency with which the treatment is given to the patient.

Stakeholders relevant to adverse affect:

RCA of health care system helps in understanding the above mentioned points and affects the individual, client who actually receives healthcare. It is to be agreed that not much has been done in this field to understand the root cause behind and abnormality but as time goes by there are individual studies taken up to understand the issue going behind in health care systems.

Health care system

Hospitals

Doctors

Nurses

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