Running head: Organizational Systems Task 21Organizational Systems and Quality LeadershipSAT Task 2Makayla LaneWestern Governors UniversityUpdated: 2/1/19
Running head: Organizational Systems Task 22Organizational Systems and Quality Leadership SAT Task 2A. Root Cause AnalysisThe primary reason for completing a root cause analysis is to solve a problem. To do this it is imperative to identify the problem and the factors that are causing it. What happened, how it happened, and why it happened are the main ideas of a root cause analysis. Performing an RCA helps to identify the root of the problem allowing the team to fix the problem and putting together a plan of action to implement to stop the problem from reoccurring. A1. RCA StepsIdentifying the problem is the first step to starting a root cause analysis it is important thatthe information obtained concerning the problem is as thorough and factual as possible. The gathering of information can stem from resources such as the patient’s chart. Setting up a timeline to organize the occurrence of events is helpful too. When gathering the information, it isimportant that the person gathering it was not involved in the patients care. Step two is identifying ideally what should have happened in the event. It is important forthe team to identify what would happen if it were “perfect world” conditions. In this step it would be helpful to do an additional flowsheet of what would happen in perfect conditions for comparison to the flowsheet of what the actual events were. The tertiary step is asking “Why?” experts recommend doing these five times to get downto the underlying cause of the problem. During this step teams look at direct and indirect causes to the problem. In this step it is useful to use a fishbone diagram to show possible causes of a certain problem. Updated: 2/1/19
Running head: Organizational Systems Task 23Step four is based on determining causes. Casual statements are made up of the cause, effect, and the event. This step paints a picture of current conditions and the actions that have contributed to negative patient outcomes. Forming a list of corrective actions is what makes up step five. In this step the team puts together a recommendation for change of practice to prevent this problem from occurring again. In this list there’s the possibility but is not limited to standardization of policies, updating or improving software, educating staff, or standardizing equipment. In the sixth step a summary of the implementation is written and shared. In this summary the incident will be described followed by the implementation of new practice to stop the reoccurrence of this negative patient outcome. With this the goal is to increase patient and staff satisfaction.