Introduction
Over the past five decades, there has been a systematic gradual change in the health centers section. Theses dynamics have necessitated for large health companies to form a quality management plan aimed at increasing patient safety through the provision of transformations governed by high performance, answerability, and discipline. The National Center for Patient Safety has not been left behind in this movement directed towards the improvement of patient safety through the Department of Veterans Affairs. The Veterans Health Administration is a component of the United States National Center for Patient Safety helping over 5.8 million patients in more than 1,400 health care establishments. The objective of this desertion is to create a quality management plan in consideration to the root cause analysis (RCA) of the Department of Veterans Affairs in the National Center for Patient Safety.
Introduction to Root Cause Analysis
The root cause analysis in health care is extensively used as a means to reveal the principal causes of certain ailments that require medical attention. In actual fact, the root cause analysis is a process that involves a series of questions associated to the incident directed towards establishing the most basic causes of a hazardous incident. This procedure was initially implemented by the National center for Patient Safety of the United States Department of Veterans Affairs. The analysis focuses on prevention rather than blame through a thorough scrutiny of the health system vulnerabilities and individual performance. The analysis management plan mainly concentrates on correcting the system mode of communication, training, and setting up of tools and tasks in a manner that promotes patient safety. The question asked is centered on the improvement of the system since harm of a patient is attributed to the failure of the system not an individual.
The following are some of the triggering and triage questions asked in a root cause analysis.
- What happened?
- Who was involved?
- When did it happen?
- How severe was the actual or potential harm?
- What is the likelihood of Recurrence?
- What were the consequences?
The Root Cause Analysis in the Department of Veterans Affairs (VA)
The root cause is the elementary breakdown or malfunction of a procedure which, when remedied, prevents a repetition of the predicament whereas the root cause analysis is the logical procedure of determination of the accurate causes of the problem. The department of veteran affair performs the root cause analysis to promote customer safety and to thwart turn backs and client escapes due to amplified recurrence of unhealthy incidences. However, VA department appears to be far from the abolition of harm imposed on some patient by providing the appropriate patient safety. Therefore, the National Center for Patient Safety requires take assuring steps aimed at the realization of a culture promoting patient safety in the VA department. The principal area requiring complete change in the VA department is the surgical section.
The main purpose for a comprehensive management plan is equipping staffs with analytical tools and training programs aimed at improving patient safety in surgical operation. This know-how and tools will increases the thoughtfulness in circumstances or situations where human error can transpire as well as teamwork proficiencies needed for effective communication of safety alarms and correcting insecure circumstances. Among the objectives that are to be achieved in the surgical sector include decreasing the rate of device related bloodstream infectivity and pneumonia in ICUs. Other objectives include reducing antibiotic resistance infections, decreasing mortality rate among patients undergoing surgery, elimination or speedy treatment of blood clots, improved on time surgery starts, and lessen in nursing turnover.
A Quality Management Plan in the Department of Veterans Affairs
It is important to note that people or patients requiring services offered by VA department are usually old, sicker, or with lower salaries than the other population. Therefore, a quality management plan should be adequately equipped with inclusive aspects aimed at increasing patient safety rather than making profit.
The first stage is the early introduction of early teamwork training among the medical stuffs which will ensure an increased positive perception of safety measures. Therefore, the team will be able form strategies that enhance prevention of inadvertent harm to patients by understanding the causative factors. Team work among health providers facilitates risks and vulnerabilities identification and makes control measures that enhance a safe medical practice environment.
The other component of a quality management plan identifies safety hazards or the root cause of a problem in the provision of medical services using the root cause analysis. The reactive method of root cause analysis triggers a close call or adverse events with severe potential of harm. The analysis also involves a multidisciplinary and confidential investigation aimed at determining the causes of hazardous events or actions. These investigations can be in the form of interviews, review of health documents, careful observation, and simulation of an event. Then after the root causes are determined a cause and effect workflow diagram is drawn outlining the major causes and interventions developed to prevent or minimize future recurrence of the same situation.
Safety measures can only be achieved with the use of comprehensive tools aimed at enhancing the entire system built on safety principles. The VA department should adopt various strategies involving well supplemented technology to communicate safety measures among patients. This involves training competitive physicians to undertake patient safety curriculum workshop aimed at educating patient safety principles and techniques to medical student and residents. Use of the appropriate tools and devices ensures that deliberated interventions are implemented successfully. On the other hand, wrong choice of tools will increase result to poor implementation which eventually leads to increased disaster or hazards. To avoid blaming one another, stuffs should be trained to handle a wide range of tools they operate on a daily basis.
After the root cause of the problem has been analyzed the VA department has to take implementation actions in the order of their hierarchy, that is; strong, intermediate, and weak or less prioritized actions. The organization should identify strong actions such as improvement in or adoption of new software’s in the surgical department, simplifying and removing unnecessary steps in the health safety plan, provision of standardized surgical improvement, targeting new device with usability testing before the actual purchase, and tangible involvement leaders in supporting patient safety. The intermediate actions encompasses such measures as the reduction of redundancy through training, increasing the members of staff in surgical department so as to reduce workload, creation of sterile surgical environment so as to reduce destructions, use of checklists, and enhance the mode of communication and documentation. Others weak but still relevant measures of safety include such actions as conducting double checks before operation, use of warning and labels, development of novel procedures and policies, and additional study and analysis. The integration of strong, intermediate, and weak actions will enhance the safety procedures outlined in the surgical section of VA.
Conclusion
The Veterans Affair health department should endeavor to create a culture directed towards patient safety through conducting the root cause analysis to determine the weaker areas of the organization and then use a comprehensive quality management plan to remedy the situation identified. In this context, the root cause analysis outlines the surgical sections as the most delicate and weak area of the entire organization. The quality management plan, with regard to the root cause analysis, aims at increasing accountability and elimination of the blame in the event that hazards occur. Moreover, the analysis focuses on errors made as a means realize the weaknesses in the system and enable future prevention of such recurrence.
References
Andersen, B., & Fagerhaug, T. (2009). Root Cause Analysis and Improvement in the Healthcare Sector. New York: ASQ Quality Press.
D'Agostino, D. M., & Shear, W. B. (2008). Department of Veterans Affairs: Improved Measures. Philadelphia: DIANE Publishing.
J. C. (2005). Root Cause Analysis in Health Care: Tools And Techniques. New York: Joint Commission Resources.
Leonard, B. (2009). Department of Veterans Affairs. Philadelphia: DIANE Publishing.
Percy, A. (2009). Quality initiatives undertaken by the Veterans Health Administration. New York: Congress of the U.S.
Teleki, S. S., & Frush, K. (2012). Improving Patient Safety Through Teamwork and Team Training. New York: Cengage Learning.
