Introduction
This paper will introduce a proposed quality improvement initiative within a commercial healthcare organisation. The basis for this will be considered in the rationale for the project. The chosen project is a Root Cause Analysis (RCA) process.
Varying perspectives will be identified from an extensive literature review. What evidence there is to support the RCA project will be reviewed and competing ideas discussed.
The aims of the improvement project will clearly state what the project should achieve and using a driver diagram the objectives will be illustrated.
Finally through a brief analysis of evaluation methodology, the chosen Action Evaluation method will be detailed through a proposal of what activities will be required
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Nobody is perfect however we should strive to learn from our mistakes so that we do not repeat them.
Currently the company has a system of recording customer feedback and is extremely good at containment so once alerted to an issue it is fixed and as far as customer service goes would be rated highly on this front. However to date no real trending or analysis of the feedback has been undertaken and an opportunity to learn from feedback being received from customers is being missed.
A problem which arises may only be one manifestation of a root cause so by addressing one root cause properly, a multitude of possible problems can be solved and the likelihood of them occurring be reduced. The time and resources expended continually fixing similar issues can be reduced by getting to the source of a problem and fixing it there. A Root Cause Analysis (RCA) system would allow the company to work through a structured process for the identification of issues and to address them at source. It is imperative that this system be effective so that recurrence of similar issues does not happen. While customers can accept that mistakes do occur, they are less accepting of repetition of the same errors with customer perception of quality being adversely
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A key literature review found the majority of problems are found to have multiple causes (WS Atkins Consultants Ltd, 2001). It has been found that people inherently tend to look for one fundamental reason for a problem (Okes, 2008; Wu, Lipshutz, & Pronovost, 2008) and that people find it difficult to accept this (Garavaglia, 2008). A key tenet of RCA is the “chain of causality”, that when you can identify a chain you can then show where your systems need to be developed (Mengis & Nicolini, 2010). Systemic Process v Individual Blame
There is an element of RCA which does try to identify ‘who is to blame?’ (Okes, 2008) but the majority of research showed a clear focus on moving away from individual blame to a focus on fixing the systems (AHRQ, 2012; Mengis & Nicolini, 2010; Wu et al., 2008). RCA should be a learning tool (Paul et al., 2014) with a focus on prevention (World Health Organisation, 2012).
It was interesting to note though that a number of papers did have a person centred focus. An ethnographic study in two NHS hospitals showed that although originally being used as learning tool, RCA was also being used as a Governance tool in the aftermath of an incident (Nicolini, Waring, & Mengis,
Mistakes are made by everyone whether it be because of confusion, lack of correct information, or just an accident. Mistakes are what make us human because we can't be perfect
Nobody is perfect. Some people have insignificant shortcomings that would not affect their life; but others have major flaws, which might cause big issues.
It is human nature for everybody to make mistakes. Some mistakes are as little as a typo that can simply be whited out and corrected. Some as big as infidelity in a relationship. Some mistakes are easily forgiven and others not so much. But there is one thing for sure, if mistakes are never made, a person will never know their true purpose in life. Now of course most mistakes you will have to pay for but, every great person has made some sort of mistake to get them where they are now. Every mistake in life is a lesson that contributes to making people successful.
The world of healthcare changes every day. Technology, as we know it evolves and changes the actual care that patients receive and even post care as well. It has been determined that most faults are caused by system failures. When a break in the system has occurred it must then be decided where the,” inefficiencies, ineffective care and preventable errors” to then influence changes within the broken system (Hughes, 2008). Improvements sometimes can begin with measurements and benchmarks which in turn will allow organizations to assess the trouble spots and broken areas within the system. Many times those broken areas within the system will be owned by the humans who operate within these systems. According to the Institute of Medicine (IOM)
everybody makes mistakes. Some people mistakes are worse than others but, that not our place
As a health-care professional, it is understood that the health and well being of a patient is top priority. The dedication to provide care and protection to each patient is ingrained into the very basics of nursing education. However, despite this commitment, medical errors that adversely affect the lives of patients are made everyday worldwide. These types of events are referred to as Sentinel Events. When such an event occurs, there is a need for an immediate investigation and response. This investigation and response is addressed using a methodology called Root Cause Analysis (RCA). With the understanding that mistakes do happen, it is the responsibility of the healthcare system
It is a step of defining the goals of the projects and the results are aimed at reaching certain levels of productivity of customer satisfaction. The second stage is measure, and it is the stage of collecting data and facts and evaluating current operational performance. The third stage is analyze with the purpose of developing methods and theories that will best suit the solving of the problem; it is also a stage of detecting cause-and-effect ties of the processes. The fourth stage is improve, it is aimed at generating ideas for reaching the desired process improvement. Finally, there is the control stage that is about monitoring the operations to find out whether the process of improvement is smooth and the problems were solved (Meredith & Shafer,
Palmer, Ted. A Profile of Corrctional Effectiveness and New Directions for Research. State University of New York Press: Albany, 1994.
Evaluation of Two Theories of Attribution One attribution theory is the correspondent inference theory by Jones. and Davis (1965). This theory was developed on Heider’s idea that the observer has a general tendency to make internal attributions. This is because it is easier to say that the cause of someone's behaviour is something within the actor as it makes the world seem more stable and predictable, rather than having to make an attribution for a person. For every situation, this would make the world seem less stable and more unpredictable than the..
Good leadership, fostering a culture of change and safety, team work are essential in implementing quality improvement and risk management in the organization. Leaders and the governing body must demonstrate commitment to the processes and define their expectations for all stakeholders. Leadership team should make sure that the team’s attention is focused on the core business of the organization, which is to provide care and treat patients in a safe and high quality clinical environment. There are different tools that can be used for quality improvement that also applies to analyzing risk issues. These are measurement of quality, benchmarking, RCA, FMECA, and so
Gilbert, E.A., Tenney, E.R., Holland, C.R., & Spellman, B.A. (2015). Counterfactuals, control, and causation: Why knowledgeable people get blamed more. Personality & Social Psychology Bulletin, 41(5), 643-58. doi:10.1177/0146167215572137
Nobody is perfect and as we move forward in this era of self-knowledge and self-discovery, it is vital to acquire the ability to recognize our own mistakes. We all do some mistakes at some point of our lives which hurt another person. The difference lies acknowledging that we have done something wrong, some acknowledge immediately and some take time.
In conclusion, humans use attribution to explain causal relationships in the world and to explain these relationships situational or dispositional factors are used. The two errors in attribution that are most commonly made are the fundamental attribution which involves overestimating the role of dispositional factors and underestimating the role situational factors and self- serving bias which is when people take credit for their successes by attributing them to dispositional factors, and dissociate themselves from their failures by associating them situational factors.
Attribution theory suggests that when we observe an individual's behavior, we attempt to determine whether it was internally or externally caused. That determination depends largely on three factors: distinctiveness, consensus, and consistency. Our perceptions of people differ from our perceptions of inanimate objects.
When people make mistakes, they can either take responsibility for that mistake or they can lie about it. When people choose to take responsibility for their mistakes, it reveals good character. The only way to really learn from your mistakes is to take full responsibility for them. For people to become better, they have to make mistakes; it is inevitable. It is not good if they don't make mistakes, because then they aren't learning anything.