Lesson Learned 6 QUESTION 1
Lessons Learned Posting by Tuesday at 11:59 pm EST: You will share the information that you learned from your course readings, your peers, and your research.
Assess how your initial understanding of the topic differs from your present views. Define the lessons (minimum 1) learned and the outstanding questions (minimum 1) that you still may have had on the topic.
USE THE READINGS ATTACHED AND THE DISCUSSION POST BELOW TO ANSWER QUESTION 1. HALF A PAGE
DISCUSSION 1 Harsus
REPLY TO THE POST AND INCLUDE A REFERENCE
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RCA is a preventive tool. It stands for root cause analysis. In the healthcare field, many errors occur when helping patients to recover from sicknesses. For instance, in November 2014, the journal Pediatrics reported that an annual average of 63,358 medication errors occurs in children younger than age 6 in the United States in nonhospital settings and that 25% of those errors are in infants, younger than 12 months old. This means that a medication error affecting a child in the United States occurs every eight minutes.
RCA is a tool used by healthcare organizations to identify, and prevent future occurrence of these active errors(errors occurring at the point of contact between humans and a complex health care system) and latent errors (hidden problems within health care systems that contribute to adverse events) Zulkowski, K. (2018).
Most adverse events happen during medical care. Some may be life-threatening, major errors, while others may be problematic but not life-threatening. By understanding the why root cause of an event, an organization can improve patient safety by preventing future harm. A good root cause analysis allows for the design and implementation of a solution that addresses the failure at its source.
According to IHI (Institute for Healthcare improvement), RCA is conducted via a multi-disciplinary team that includes the following:
· Subject Matter Expert(s)
· Individual(s) not familiar with (naïve to) the event or close call Process
· A leader who is well versed in the RCA process
· Front line staff working in the area or process
· Patient representative
RCA utilizes tools and techniques such as a Cause and Effect Diagram and the Five Whys to isolate the primary cause of an event from incidental factors that may or may not have contributed to the event.
Once the root cause is identified, the team must establish that it meets the Five Rules of Causation:
1. Clearly shows the cause and effect relationship
2. Uses specific and accurate descriptors for what occurred
3. Human errors must have a preceding cause
4. Violations of procedure are not root causes but must have a Preceding cause
5. Failure to act is only causal when there is a pre-existing duty to act
Zulkowski, K. (2018). Root cause analysis: An effective QI tool. World Council of Enterostomal Therapists Journal, 38(1), 35–39
REPLY TO THE POST AND INCLUDE A REFERENCE
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Measures and Metrics
I have selected the Process Measures and the Outcome Measures.
Structure measures: These measures include available resources, staff, equipment, competencies, inputs, facilities, and characteristics of the HCO. They reflect how the organization is (or was) set up (Olden, 2019, p. 294).
Process measures: These measures include what work is done, how it is done, and which activities are involved. They reflect the HCO in action after someone presses the “on” button (Olden, 2019, p. 294).
Outcome measures: These measures include what happens (or happened) as a result of the structures and processes. They reflect the results and effects (Olden, 2019, p. 294).
The structure/process/outcome approach is another way to think about types of performance HCOs must control. These three performance dimensions were developed by Avedis Donabedian (1966, 1988) primarily for medical care. They were later extended to other kinds of work. Managers should realize that structures and processes strongly affect outcomes. Thus, to improve outcomes, managers should improve structures and processes (Olden, 2019, p. 294). A strong structure measure and process measure is needed to ensure a successful outcome. For example, when the pandemic hit, I used all of my available resources and staff to implement a policy and procedure. After the structure was built, the process measure came into play to ensure the policy and procedure, how it’s done, and how it will affect the practice. Due to the excellent structure and process, I had an incredible outcome of how we handled the spread of COVID-19 in our office and the precautions are taken. I believe these measures are like building a house! You must have a good structure and process to have a great outcome. According to Wright (2021), Patient Reported Outcome Measures (PROMs) are standardized surveys assessing functional status, health, and wellbeing. Contemporary movement toward the evaluation of services through consideration of the patient perspective is reflected in the development and use of PROMs. Cognitive interviewing (CI) is a promising method of developing and refining PROMs, however, there is variability in the CI procedures implemented. This is a great example of how process measures and structure measures lead to outcome measures.
Olden, P. C. (2019). Management of healthcare organizations: An introduction (3rd ed.). Retrieved from
Wright, J. (2021, February). Cognitive interviewing in patient-reported outcome measures: A systematic review of methodological processes. Retrieved from