Risk Management - Situation Analysis Using the FOCUS Model - Research Paper Example

Risk Management Table of Contents TASK 61 3 A. Situation Analysis Using the FOCUS Model (Find, Organize, Clarify, Understand, Select, and Act) 3 A Finding a Process for Improvement- Process that Needs Improvement 3 A. 2. Organization of a Team with Knowledge of Process 5 A. 3. Clarification of Current Knowledge re: the Process 6 A. 4. Understanding of the Causes of Variation of the Process 8 A. 5. Selection of the Process Improvement 10 B. Improvement Plan Using the PDCA Model (Plan, Do, Check and Act) 12 B. 1. Plan 12 B. 2. Do 13 B. 3. Check 13 B. 4. Act 14 C. Unit Protocol Containing at Least Five Staff Directives 14 TASK 63 16 A. Root Cause Analysis 16 B. Causative List- Organization of Causative Factors 17 References 19 TASK 61 A. Situation Analysis Using the FOCUS Model (Find, Organize, Clarify, Understand, Select, and Act) A. 1. Finding a Process for Improvement- Process that Needs Improvement There is merit in going through the process of admitting and administering to the needs of Mr. X in this particular scenario. There is value as well in tracing where and how the flaws in the processes are generated and located. The nature of the emergency, first and foremost, is an important consideration. This case is about psychiatric emergencies, where care providers have to deal with crises relating to patient behavior. In this instance the emergency is of the nature that is non-medical. It is psychiatric, and the goal is to be able to up the readiness and the level of understanding of the care staff when dealing with such emergencies. This process is to benefit from the use of the PDCA cycle, as well as the FOCUS model-based situation analysis (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). In the case at hand, the patient was admitted into the ER as a stroke suspect, but the tests yielded negative for stroke with the CT scan. The urine tests showed the presence of opiates, leading the staff to suspect the use of IV drugs by the patient. He is negative for aphasia, and has no signs of having had a seizure, even though that was the suspicion,. He was under observation the past 24 hours. Not being certain of the problem in Mr. Xs case, the care staff moved him to a unit on acute care. There he is left without restraints, shirtless, and wearing just a pair of boxing shorts. As nurse administrator, the flag for Rapid Response showed the patient hysterical and asking for help. The intervention given was an facial mask-delivered oxygen, and following the protocol of getting the cardiac monitor attached to the patient as per the Rapid response protocol. The staff seemed paralyzed and unable to know how to deal with the crisis. The protocol fails, as the patient only takes a minute to start acting up again, and removing the mask and the monitor. The EKG reading was normal, and the protocol having failed, the staff did not know how to proceed. The patient escapes and is seen at home. The patient returns the next day with a headache and discomfort in the chest area that are self-reported. The same unit as the previous day accommodates him, but the staff are understandably wary. Three hours hence they recorded another emergency from the patient The patient complained of pain in the stomach. The doctor is called, but the nurse in charge of the case and the other staff keep their distance from Mr. X (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). Looking at the scenario, clearly there are several areas that seem deficient. One, when the patient initially acted up and asked for help, the available protocol for Rapid Response seemed inadequate to deal with the kind of drama and commotion that came with Mr. X. This needs further investigation as a process and as a protocol. Next, when the protocol failed and the patient acted up by tearing up the monitor and removing the oxygen mask, the staff were at a loss as to what to do. This is also a gap- there is no process or protocol to follow in such a circumstance. A birds eye view look at the entire scenario will prompt an outsider to think that the lack of sedation can be one of the causes. This as far as the initial protocol is concerned. The patient was clearly in distress, while the vital signs were normal. This indicates that something else may be at work. It is up to the physicians to determine whether sedation is called for in this scenario, given the condition of the patient. There was the suspicion of opiates use, and the suspicion of a seizure having occurred prior to the action by the patient that caused the commotion. Thirdly, that the patient was able to loosely move around without restraint. Without effective restraints that could have been available if the protocols were in place, the staff was completely vulnerable to any acts of violence from the man. This points to lapses in the processes tied to security. The staff and the hospital in general were fortunate that the patient was not violent and did not cause harm to anyone or damage to property. Taking a step back, this situation could have been more dire. Peoples well-being and property could have been compromised by the actions of patient X.. There was a lack of safeguards and protocols on the part of the hospital and the staff to make sure that such events did not happen, or did not cause harm if they did happen ((Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). Everything considered, the Rapid Response protocol, and the processes tied to that need improvement. The needed improvements are in the area tied to bolstering security and securing the well-being of the patient as well as the staff and the general public (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). A. 2. Organization of a Team with Knowledge of Process The scenario identifies the major parties making up the team that responded to the crisis presented by Mr. X. There was the nurse administrator, the physicians, the staff in charge of the respiration interventions, an ICU nurse, and assistants to the physicians. The staff nurses played a big part in the scenario, taking charge of the various presented interventions given to Mr. X. Being in the know, and being exposed to the experience firsthand with Mr. X, and being part of the Rapid response protocol that was found deficient, these persons occupying the roles are to be made part of the team. In addition, there may be some consideration placed on including other specialists and care staff in the team to go through the process of improving the problematic situation at the emergency room. These additional team members would be specialists in non-medical conditions, such as psychological and psychiatric conditions that need special interventions, as well as trauma specialists. Security personnel may also be included in the team, given what happened when Mr. X was able to bolt past the care staff and essentially get past security in order to go home. Under less lucky conditions this one single detail, of the patient being able to escape, could have resulted in human and property casualties. This is a very large security risk and danger, emanating from lapses in the process in this respect (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). A. 3. Clarification of Current Knowledge re: the Process As discussed in A.1, there are various holes and shortcomings present in the current process. The protocol prescribed for Rapid Response, for one is deficient and lacking in provisions for when the patient is in full control of his body strength, and able to escape and to free himself from the breathing mask and the cardiac monitor. As well there are holes with regard to provisions in the protocols and the process when dealing with suspected psychiatric cases, as is the case with Mr. X. He was tested positive for urine traces of opiates, for one. He is under suspicion of having had a stroke and a seizure, conditions that could have prompted the care staff that the mans psychological capacities may have been affected by the compromising of the integrity of the brain and the patients mental faculties. When the patient asked for help, that could have triggered the care staff to consider the results of the tests and the condition of the man as he presented himself, and to craft an intervention that was more suited. On hindsight, it was prudent to have acted in a way as to make sure that the patient was secured and unable to inflict harm on himself and others. This he was at liberty to do, though he did not, given the absence of provisions in the protocol for Rapid Response that dealt with such cases. On hindsight it is clear that the process could have benefited from considering sedation, or from making sure that the patient was secured, together with the staff attending to the patient (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). Considering the whole scenario as an end-to-end process, we see several gaps. First is the gap relating to crafting a Rapid Response that is relevant to the conditions present. This means crafting an intervention that is suited to the patient vital signs and the results of the tests. In the case of Patient X there was no consideration placed on the fact that the man tested positive for opiates in the urine. There was no consideration likewise on the fact that he was suspected of compromised integrity of the brain and mental faculties due to the suspected occurrence of a stroke and the occurrence of a seizure/seizures. A Rapid Response protocol dealing with the scenario too, could have considered that where the man asking for help had stable cardiac readings and had the conditions present as discussed above. They could have considered using another protocol, or a modification of the existing Rapid Response protocol, as this seemed to have been necessary given the situation. Next, the protocol failed and Mr. X was able to remove his mask and his cardiac monitor with little resistance, and was able to basically move around unfettered within the confines of the unit. Given this, there was no protocol on standby to deal with the emergency. The patient, with that kind of physical power could have caused tremendous harm to himself and to others. Security could have been bolstered. Interventions could have been put in place. These are the gaps in the process, actions that were done and actions that were omitted and not planned for, that contributed to the incident. These are serious lapses, born out of the fact that Mr. X was not bedridden and incapable of making use of his physical power. On the other hand, Mr. X was shown to have full control of his physical faculties, and was able to exploit gaps and omissions in the protocol that was in place at the time of the incident (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). A. 4. Understanding of the Causes of Variation of the Process The preceding discussion presents us with a kind of cause and effect and gaps analysis that shows us just how the incident transpired. It also shows us just how the patient was able to breach the existing safeguards in place, or the lack of safeguards in place. In the main there are three gaps. These gaps all fall under one umbrella gap – that of the current process failing to take into consideration the creation of protocols to deal with psychiatric and other non-medical emergencies. This is the case in the scenario being considered here. The three gaps that fall under this umbrella gap meanwhile, are as discussed earlier. In a gap analysis and cause and effect analysis, these three gaps flow from each other in a causative fashion. At the head of the entire process ,there is a failure on the part of the existing Rapid Response protocol to include interventions or steps to deal with suspected psychiatric emergencies when the symptoms present themselves. Looking at the protocol employed, it clearly lacked provisions for when the patient has the potential to be a physical danger. Ditto for when the patient has compromised psychiatric and psychological faculties as to be a potential danger to himself, other people, and to property. This in gist is the mother gap. Meanwhile, within the process being analyzed here, there are two further gaps. The first among them is the gap in not being able to include provisions to secure the patient for his own safety. Here sedation and or the use of restraints could have helped, as a matter of course, with or without the threat of physical harm. This gap is understandable, given that the staff had no prior experience with dealing with such psychiatric cases. On the other hand, this gap exists. Moving on to the second gap of two other gaps, it is with regard to interventions and provisions in the protocol to address situations when the security provisions in place are breached. In the scenario being analyzed, Mr. X was able to remove the masks and the monitor, and to escape the facility, with ease. The gap is in not being able to plan for and to secure the situation when the patient is able to breach the existing security measures (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). In diagram form, the process as it was followed in the case is as follows. Essentially every component of the overall process presents the gap areas, or indicates the parts of the overall process where the breaches and gaps are in place. Each step in the diagram is also the location of a gap in the process, as illustrated below (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). In the diagram above, the data on the patients condition upon admission exists, but is not made part of the process of crafting the interventions tied to Rapid Response. In the second stage, the protocol does not include provisions for dealing with non-medical emergencies, such as the case with the psychiatric emergencies that gripped Mr. X. In the third stage, there were no interventions in place to deal with situations where the patient, in control of his physical faculties and wits, is able to breach any security measures in place to escape from the facility and to generally move around unhampered by the staff, potentially causing harm to himself as patient, to the staff, other people in the facility, other people in the community, and to hospital and community property (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). A. 5. Selection of the Process Improvement The ideal interventions for the case at hand involve plugging the holes and the gaps in the process. This is in order to reduce the risk of re-occurrence and to make the staff and the hospital better able to deal with such non-medical emergencies. Included here are psychiatric emergencies. At the top of the process, patients being admitted to the emergency room must be screened for exhibiting the potential for such psychiatric and other non-medical emergencies as determined by the specialists. In cases where certain threshold criteria are met for the determination of the presence of or the potential for non-medical emergencies, the next step would be to plug the holes and the shortcomings of the protocol for Rapid Response. This can be done by incorporating interventions to secure the safety of the patient. This can take the form of sedation, or the setting in place of restraints. These interventions would be on top of the interventions currently in place for both medical and non-medical emergencies. In the current case this would mean securing the patient physically, on top of the administration of the oxygen masks and the use of the cardiac monitor. The sedation and restraint process should be well-elucidated too, and well-managed and assessed for safety and efficacy. The interventions too, including sedation, will have to incorporate the results of the initial screening and tests on the patient, upon admission. Finally, additional measures and protocols have to be put in place to make sure that in the case of breach of the initial set of measures, fall back measures are in place to secure the safety of the patient and the staff (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). B. Improvement Plan Using the PDCA Model (Plan, Do, Check and Act) B. 1. Plan The preceding discussion presents the fundamentals of a plan to improve the process of dealing with situations such as those presented by Mr. X. In general the discussion is also about adapting current Rapid Response emergency protocols in the facility so that they are able to account for non-medical emergencies such as psychiatric emergencies. The risks are great in the event that there are no modifications in the process. The risks and consequences are in terms of the future harm that other patients may cause to themselves and to others, and in terms of the legal and financial liabilities that can accrue to the hospital in such circumstances moving forward (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). There are three parts to the plan, corresponding to the three major gaps in the process. The overall plan is to overhaul the process by including interventions at the screening stage, at the Rapid Response stage, and at the stage where the protocols in place are breached. In each of these stages or gaps the overriding consideration is in being able to account for the possibility of non-medical, psychiatric emergencies erupting with little or no warning, at the time when care is being administered, or at the time of admission into the emergency department or critical care unit, as the case may be. The idea is to be able to plug all of the three identified holes or gaps with the appropriate measures and interventions, to make sure that non-medical emergencies are accounted for in the planning and in the protocols. This is to make sure also that staff are prepared and ready in the case of the re-occurrence of situations similar to what transpired with Mr. X. (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012) B. 2. Do The general action plan would consist of several phases, for each of the gaps or interventions planned. Essentially there are three, and they are all related to each other, in terms of the phases or stages or gaps. In the first stage, the plan is to assemble the team that was in place at the time of the incident, and to supplement the team with new members representing the experts from the different non-medical emergencies known. Chief among them are the psychiatric emergencies similar to those presented by Mr. X. The second step is to then craft specific changes in the Rapid Response protocol to include recommendations from the first team, and to implement them within the unit. This means securing the physical changes necessary to implement the changes. This also means reorganizing the security staff and other involved staff. The third step is to draft contingency measures in security and related matters to make sure that if things fail, there are back up procedures and protocols to make sure that the patient is secured together with the hospital staff and the general community (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). B. 3. Check There are several ways to check the integrity and the effectiveness/workability of the plan presented above. One is via actual runs with actual patients. The other is to review the existing literature and to consult experts and other facilities who have done similar things as are contemplated in the plan, and to benchmark the plan against real-life cases in the literature and in the involved medical facilities. The latter takes care of the fact that in the real world, it will take many years before the right cases present themselves to be able to stress-test and validate the plan presented and the procedures and protocols included in the plan (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). B. 4. Act As discussed in the task details, this step is to be omitted, owing to the fact that for this exercise there is no requirement for the carrying out and actual execution of the plan in real life. C. Unit Protocol Containing at Least Five Staff Directives This unit protocol is substantiated by insights from the preceding analysis and discussion, and draws on practical implications from that analysis. The following are the crafted directives (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012): 1. Draw up appropriate screening guidelines and red flags to warn the staff of the potential of an admitted patient for undergoing psychiatric and other non-medical emergencies. 2. Make sure to notify the appropriate expert or experts when the red flags are present, and to make sure that such experts are available on call at any given time 3. Train staff with regard to the screening procedures 4. Draw up sedation and restraint procedures in consultation with subject matter experts, with care for efficacy and safety. Guidelines for sedation and restraint are to be explicitly stated and strictly followed. All staff are to be trained in this area. 5. Drills are to be conducted on a regular basis with security staff to make sure that back up measures are effective and known to the care providers, in case of the escalation of the non-medical emergencies of the nature similar to what happened with Patient X (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). TASK 63 A. Root Cause Analysis The key event and the patient outcome/effect is the death of the patient. The aim of this exercise is to trace the effect back to their root causes. The case provides many details to illumine an analysis of what went wrong, and what the root causes of the patients death are. Tying the outcome to the intervention, and to the implications of the included discussion, there is a correlation it seems with the heavy sedation of the patient and his eventual death. This is one of the chief causes or root causes, the fact that the sedation seemed to have been overdone, and seemingly in violation of procedures and prescriptions tied to how much and how to administer sedation to patients in such circumstances. The following details the list of such identified root causes, as they are gleaned from the case facts. These are to be arranged in order of descending importance in the next section (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012) 1. There was a shortage of ED physicians to adequately handle the escalated load at the time of the incident 2. There seemed little coordination among staff handling Patient B. 3. There seemed little coordination between patients in terms of dividing load among patients 4. There seemed little by way of a system for prioritizing attention and allocation of equipment to patients 5. While Nurse J had training on sedation moderation protocols, she did not seem to have coordinated with the ED physician on the safety of the prescribed sedation doses, and followed the doctors prescriptions with little or no input or protestation 6. There seemed to have been no protocol in place for determining when to call the code, based on the O2 saturation and BP readings. The code was called only when the son reported the absence of breathing. On the other hand, the alarm had been going off for some time prior to that, with critical O2 saturation and BP levels recorded 7. There was an absence of capability for advanced care in the hospital, necessitating transfer 8. There was little consideration of the conditions present in the patient when determining the level of sedation and even the appropriateness of sedation for the patient. 9. There was no indication that the ED physician complied with the guidelines for moderate sedation (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). B. Causative List- Organization of Causative Factors Weighing in on the causative factors identified in the previous section, it is clear that those causative factors directly tied to the standards for sedation and the procedures for determining calling the code are the most critical. Below are the causative factors listed in order of decreasing importance or degree of impact to the patient outcome (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012): 1. There was no indication that the ED physician complied with the guidelines for moderate sedation 2. While Nurse J had training on sedation moderation protocols, she did not seem to have coordinated with the ED physician on the safety of the prescribed sedation doses, and followed the doctors prescriptions with little or no input or protestation 3. There was little consideration of the conditions present in the patient when determining the level of sedation and even the appropriateness of sedation for the patient. 4. There seemed to have been no protocol in place for determining when to call the code, based on the O2 saturation and BP readings. The code was called only when the son reported the absence of breathing. On the other hand, the alarm had been going off for some time prior to that, with critical O2 saturation and BP levels recorded 5. There was a shortage of ED physicians to adequately handle the escalated load at the time of the incident 6. There seemed little coordination among staff handling Patient B. 7. There seemed little coordination between patients in terms of dividing load among patients 8. There seemed little by way of a system for prioritizing attention and allocation of equipment to patients 9. There was an absence of capability for advanced care in the hospital, necessitating transfer (Yoder-Wise, 2010; American Society for Quality, n.d.; Garkovich, 2009; Wilburn, 2012). References American Society for Quality (n.d.). Plan-Do-Check-Act (PDCA) Cycle. ASQ.org. Retrieved from http://asq.org/learn-about-quality/project-planning-tools/overview/pdca-cycle.html Garkovich, L. (2009). Components of a Situation Analysis. Foundations of Practice. Retrieved from http://srdc.msstate.edu/fop/levelone/trainarc/09fall/session5_garkovich_handoutb.pdf Wilburn, D. (2012). PDCA Problem Solving Revisited. Accountability.wa.gov. Retrieved from http://accountability.wa.gov/leadership/lean/documents/2012_Lean_Conference/Performance_Leadership/23/Problem%20Solving%20-%20The%20Lean%20Business%20Practice.pdf Yoder-Wise, P. (2010). Leading and Managing in Nursing 5th Ed. Mosby. Yoder-Wise, P. (2010). Leading and Managing in Nursing 5th Ed. Mosby. Read More