B1. Change Theory
Lewin’s Change Theory is made up of three stages which are the unfreezing stage, the
change stage, and the refreezing stage. Unfreezing involves getting people to let go of an old
way of thinking or doing something. In regards to the scenario, this would be accomplished by
making staff aware of factors that led to the event which would heighten understanding for
the necessity of a change. The change stage involves the actual change takes place. This
requires a change in thought process and behavior. For the scenario, the change stage would be
after the roll out of education and the new pre and post procedure checklists were being used by
staff. The refreezing stage is when the changes become a habit or a standard of practice. For the
Running head: Organizational Systems Task 2
8
scenario, this would take place when it becomes a standard of practice for the staff to
consistently follow the policy and consistently use the pre and post procedure checklists as a
safety measure. During this stage, you should be able to see that the changes result in increased
safety and improved outcomes (Cherry & Jacob, 2017).
C. General Purpose of FMEA
Failure Mode and Effects Analysis (FMEA) is a structured and proactive
method to recognize and deal with prospective problems or failures of a process and their
resulting effects on the process prior to adverse events occurring.
C1. Seven Steps of FMEA Process
Step 1: Select a process to evaluate.
Choose a process that is a known problem or potential problem in your facility. It is
suggested that a large or complex process not be chosen a single process to evaluate. Instead,
each sub-process should be evaluated in its own FMEA analysis ("QI Essentials Toolkit:
FMEA," n.d.).
Step 2: Select a multidisciplinary team.
Leadership typically selects team members and appoints a facilitator. This should be
comprised of people directly involved in the process being analyzed ("QI Essentials Toolkit:
FMEA," n.d.).
Step 3: Discuss the process steps.
The team should meet and discuss the steps of the process being analyzed. Each step of
the process should be numbered and clearly defined. Flowcharts can be used as a helpful tool for
the group. Before moving on, the team needs to agree that the steps listed accurately describe
the process being analyzed ("QI Essentials Toolkit: FMEA," n.d.).
Running head: Organizational Systems Task 2
9
Step 4: List failure modes and causes.
The team must look at each step in the process and identify anything that could go wrong
including minor problems. These problems are called failure modes. Once the failure modes are
identified, the team must identify all the possible causes for each of the failure modes listed ("QI
Essentials Toolkit: FMEA," n.d.).
Step 5: Assign a Risk Priority Number (RPN) for each failure mode.
