Organizational Leadership - Root cause analysis

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The 67-year-old patient's arrival at the six-room emergency department (ED) of a sixty-bed rural hospital signals the start of a scenario tainted by nurse and physician carelessness at the facility. The son brings in the elderly guy, who is complaining of significant discomfort in his (L) leg and hip area, which he claims occurred when he stumbled over his dog. Mr. B is admitted to the triage room for blood pressure and body weight monitoring. He swears he has no allergies, despite the fact that his hip and leg hurt. Mr. B is later admitted by Nurse J that finds out that he had a history of glucose impairment. She also discovers that the old man had prostate cancer and that his last visit to a healthcare facility was his primary care physician, laboratory data where the data revealed that he had elevated lipids and cholesterol levels. The nurse’s assessment on Mr Ba also identifies that his current medications are atorvastatin and oxycodone for chronic back pain and she later takes the findings to the physician.

At the day of Mr. B’s arrival, the staffing concisted of two nurses and a physician and all these staff were occupied. This is to say that to handle Mr. B’s case, the nurse and the physician had to multitask. This is dangerous to a patient in Mr. B’s state, in that he is denied full attention by the medical practitioners. The physician, for instance, apart from handling, Mr B, he is also dealing with a 43 year old patient and an eight-year old boy. He, however, gets time to evaluate Mr. B’s condition and writes orders to nurse J to administer diazepam 5 mg IVP to Mr. B. the diazepam, however, seems not to have effect on Mr. B and this forces Dr. T to instruct nurse J to administer hydromorphone 2 mg IVP. Nevertheless, no changes take place, and this force the physician to conduct a further review on Mr. B’s medical history. He finds out that the medication has no effect on Mr. B due to his weight and current regular use of oxycodone. It hardly takes long before the medication takes the better of Mr. B and this gives room for the physician and the nurses to conduct a hip replacement on the patient. The process takes place without signs of distress from the patient.

As time passes by, the working area gets busier, especially when nurse J and the LPN gets an emergency patient. The ED lobby also gets congested with incoming patients and this makes it hard for the medical practitioners to provide full attention to Mr.B. during that time, Mr. B’s saturation oxygen alarm and indication that he is experiencing low oxygen saturation. The LPN and nurse J rushes to the room and administers the necessary help to the patient. Nurse J then engages with the evaluation of a respiratory distress patient, assessing and evaluating him, and this leaves Mr.B with a lack of regular monitoring. The old man is left to the watch of his son that informs the nurse that the monitor is alarming, an indication that his dad requires medical attention. When the nurse gets to the room, the old man is finding challenges in his breathing, blood pressure reads 58/30 and oxygen saturation is at 79%. No pulse can also be detected on the old man. A STAT Code team is called and the patient is resuscitative efforts with the aim of stimulating his breathing. The patient is found to be in ventricular fibrillation and air transportation is called for that transports him to a tertiary care facility. However, seven days later, the hospital receives information from the tertiary facility that Mr. B suffered from brain death and his family requested for a removal of the life support machine that subsequently led to his death. According to the tertiary care facility, the hospital that Mr. B had originally been treated had a moderate sedation/analgesia required that a patient remained on continuous B/P, ECG, and pulse oximeter throughout the procedure until a specified discharge criteria was met. The nurse on duty was nurse J and she had no past histories of negligence. Sufficient equipment was available on the day of Mr. B’s admission to the hospital. One thing, however, that contributed to poor patient care was the lack of organizational skills and good leadership from the team (both nurses and LPNs). Had the nurse and the LPN handled the issue differently by dedicating a lot of patient care time to Mr. B, his condition would not have ended up as detrimental.

Process improvement plan that can be instrumental in dealing with the issue

In the quest of dealing with the situation leading to the death of Mr.B, there are various measures that could have been taken into consideration. Upon the arrival of Mr.B into the facility, patient care would have taken place. Two nurses and physicians would have been assigned to monitor and provide the patient with the necessary care and support. One of the nurses would have been mandated with the role of assessing and evaluating the patient’s condition before delivering the findings to the physician. The other nurse would have been given the task of regularly monitoring the patient at the ward to ensure that he was going through a smooth recovery process and that in the event of anything, the nurse would report to the physician. The LPN always instructed the nurse to administer different types of medication to the patient without his physical presence being felt at the ward. Clearly, this was another reason that caused the deterioration of Mr.B’s health. It will thus be suitable for the physician to be present during the administration of the different types of medication to the patient. Both the nurse and the doctor also have to ensure that they have a reassuring attitude towards the patient, and promise him that despite his present condition, he will recover soon. Good communication within the healthcare facility can also be instrumental in improving the level of patient care. Through effective communication, it will be easier for the LPN to pass information to the nurses on the approaches that they have to take in administering care to the patient. In as much as there may be an increase in the incoming patients, effective communication would have been instrumental in dealing with Mr.B’s condition. Through effective communication, it is also easier to improve the relationship between the medical practitioners and the patients. a health care facility that enjoys a good relationship between the Nurse Practitioners and the physicians will always have high levels of patient satisfaction.

Change Theory

The change theory is a comprehensive description and illustration of how and why a given change is expected to take place a specific context. The model entails participation, planning, and evaluation. It entails coming up with long-term goals and identifying all the conditions that must be in place for the specific goals to occur (Burke, 2002). The health facilities across the U.S. have put the theory into the application, and this is evident from the reforms that are being witnessed within the correctional facilities for the mentally ill patients. In this case, change theory can be vital in dealing with the working conditions at the rural hospital where Mr. B is admitted. Under the change theory, the nurses and the LPN will be required to participate in the patient’s recovery process, plan on the measures that they will put in place in ensuring that he undergoes a full recovery from his current condition and evaluate his health status throughout the medical process. The nurses will also be required to ensure that they regularly monitor his condition and report any situation that may seem weird or may affect his health condition drugging him back to his previous status. The nurses, through the assessment process, also have to ensure that they record his daily status and response to medication. Implementation of such patient care can be instrumental in ensuring that the recovery process for Mr. B is significantly enhanced. As a part of the change theory, change models such as Kotter’s 8 step model and the Lewin’s change models will be vital too (Three Types of Change Management Models | The Fast Track, 2012).

The addition of the Kotter’s 8 step change model will be instrumental in the stimulation of the change theory. The model is built on eight steps that include increasing the urgency for change, building a team dedicated to change, the creation of a vision for change and communicating the specific need for change. Other steps include empowering the staff on the ability to change, creating short-term goals, staying persistent and making a permanent change (Three Types of Change Management Models | The Fast Track, 2012). In the case of the health care facility, the creation of the urgency for change will be done through memos and emails to all the staff members. I will be necessary to inform the employees within the organization on some of the reasons why it will be vital for the implementation of change in the organization, and through that, urgency will be created. The creation of goals will entail coming up with objectives that will be vital in ensuring that the facility meets the tastes and preferences of the patients. Some of these goals will include patient care, timely administration of the right medication to the patient, regular assessment and evaluation of the patient condition and maintenance of a good relationship with the patients. The change process will be aligned in ensuring that the patient care enhancement is the primary goal. The staff within the organization will then be empowered for the change process through a week long training process before the change is permanently implemented in the healthcare facility.

Failure Mode and Effects Analysis (FMEA)

Failure Modes and Effects Analysis (FMEA) is a systematic tool and approach and method that is vital in the evaluation of a process with the aim of a process in the identification of where it may fall and focus on the failures within an organization and those areas that require change (Bahret, Kleyner, Meixner, Carlson, Craggs & Plucknette, et al. 2017). The FMEA will be vital in the assessment of the steps in the healthcare process in the rural health facility, the failure modes, and in this case, it will focus on some of the factors contributing to failures within the organization or some of those areas that require change. The model will also highlight on the causes of failure within the organization (Bahret, Kleyner, Meixner, Carlson, Craggs & Plucknette, et al. 2017). Some of these causes include poor communication, lack of good organization management skills among the employees and cases of negligence. Finally, FMEA will be instrumental in the identification of some of the consequences that may come along with the failures witnessed within the organization. Some of the consequences, in this case, that may come along with the failures include reduced patient flow and the reduction in the facility’s reputation.

Members of the interdisciplinary team

The interdisciplinary team will be made of both the staff members and external experts outsourced from various other health facilities that have been in a similar situation before. Some of these interdisciplinary members will include:

3 Doctors of Nursing Practice from the facility

5 Licensed Nursing Practice from both the facility and other healthcare facilities

4 physicians

2 Registered Nurses

The administrator of the facility

The Human Resource manager

The director of the facility

Steps for preparing for the FMEA

The first step in the preparation for the FMEA will include selecting the process to analyze and this will include identification of the factors affecting the efficiency in the delivery of effective patient care. The second step will involve the selection of the people in the team and informing them of the various tasks and responsibilities that they will have to carryout to ensure that the entire process is a success. The third step will entail the preparation of the process, and in this case, it will be necessary to ensure that all the change goals are clearly identified and the implementation measures are agreed upon among the team members. The change process will have to be designed in such a way that they will meet the set objectives and goals of the facility. Finally, it will be necessary that as a part of the FEMA preparation, the team identifies those factors that could end up contributing to challenges in all the steps of the FMEA model.

Application of the FMEA steps to the change process

In the preparation step, it will be necessary for the staff to be made aware of the changes that will be implemented within the facility. As part of the change process, it will then be necessary to come up with a team that will facilitate the implementation process. The team will have to ensure that the goals and objectives for the change process are met (Bahret, Kleyner, Meixner, Carlson, Craggs & Plucknette, et al. 2017). The team will be asked to identify any failures that may end up sabotaging the entire process. Good communication among the members of the team will be vital in making sure that the change implementation process is a success. the detection of all the factors affecting the level of patient care will also be vital and this will be made possible through the help of the LPNs. Identification of the problems will help in dealing with the negative consequences that could have come along if such issues were hardly addressed. The administrator of the facility will oversee the entire change process to ensure that it is a success.

Intervention process using FMEA

In the quest for ensuring that the intervention processes are a success, all the steps of the FMEA will have to be addressed. The first step will entail choosing a process that is problematic within the facility. The problematic process in the rural health facility is poor communication among the staff that ends up leading to unsatisfactory patient care. The next step will involve coming up with a leadership team that will be play a vital role in ensuring that the change process is effectively conducted (Bahret, Kleyner, Meixner, Carlson, Craggs & Plucknette, et al. 2017). Leadership will be instrumental in the provision of charter for the launching of the team that will play a role in the success of the change process. The third step will then involve description of the processes to all the team members so that they can have a clear picture on those tasks and responsibilities that they will have to handle. The team will then identify those areas that will be a challenge during the implementation of the change process and the measures that they will put in place in ensuring that they hardly affect the entire change model (Bahret, Kleyner, Meixner, Carlson, Craggs & Plucknette, et al. 2017). The fifth step will then involve picking up of the most problematic scenario, and this case it will be poor communication and negligence among the nurses within the facility. The team will also determine the best change process that will help in the mitigation of risks of residents and those that are not among the team on being harmed. The final step will involve evaluating and implementation of the change process. In the case of the implementation, it will be necessary to ensure that the organization is divided into units that will help in ensuring that communication streams are effective and that all the staff members have clear roles and responsibilities (Bahret, Kleyner, Meixner, Carlson, Craggs & Plucknette, et al. 2017). A feedback channel will also be introduced where staff members will be allowed to report or offer suggestions on those things that can be put into place to ensure that the health facility effectively meets the needs of the patients.

Key role of nurses

The roles of nurses, in most cases, vary with their settings and type of nurse. Nurses are mandated with various roles and responsibilities. One of the roles of the nurses is the implementation of the physician’s orders such as giving medications or changing dressings, and assessing and monitoring the patients. The nurses also ensure that they evaluate the safety the medical plan of care before implementing it (Journal, 2017). The nurses interpret the patient information and assessment plan and data before making decisions on the course of action that needs to be taken. Nurses focus on ensuring that the patients meet their needs which include spiritual; emotional and cognitive needs.

Some of the key traits that a good leader needs to possess include good communication, commitment, good decision maker and confidence. Good communication helps in the delivery of content, and this can help create a good relationship between the administrator, fellow colleagues and the inmates. A good leader needs to come up with decisions that will be of great help to the organization regarding growth. Commitment and confidence can help a leader in gearing an organization towards their set goals and objectives.


Bahret, A., Kleyner, A., Meixner, A., Carlson, C., Craggs, D., & Plucknette, D. et al. (2017). 10 Steps of FMEA — Accendo Reliability. Accendo Reliability. Retrieved 30 June 2017, from

Burke, W. (2002). Organization change. Thousand Oaks, Calif.: Sage Publications.

Journal, N. (2017). What Roles Does a Nurse Practitioner Have?. Retrieved 30 June 2017, from

Three Types of Change Management Models | The Fast Track. (2012). The Fast Track. Retrieved 4 August 2016, from

May 17, 2023

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