Organizational Systems and Quality Leadership

Brief Description of the Case Study and Ethical Issues

In the case study, Mr. J. endures poor quality of services from the hospital nurses. There are two issues in the case and the first is the mix-up on diet, where the nurses erroneously serve him pork yet his religious and cultural beliefs do not condone eating pork. The second is the presence of sunburn-like features on his spine, which could be a sign of bedsores because of long periods of immobilization on his bed. These two issues should be addressed using various quality indicators and analysis tools.  

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Nursing quality indicators

According to the American Nurses Association (2007), nursing quality indicators are the elements of patient care that directly affect patient outcomes. These include patient falls, pressure ulcers, nurse job satisfaction, nosocomial infection rates, patient satisfaction with management of pain, patient satisfaction with overall care, patient satisfaction with nursing care, nursing hours per patient per day, and staffing mix (American Nurses Association, 2007). In the case study, the relevant quality indicators are pressure ulcers, lack of patient satisfaction with nursing care, and lack of patient satisfaction with the overall care. It is clear that the nurses have neglected Mr. J. and he is not satisfied with the care he receives. Moreover, he may have developed pressure ulcers due to the long periods he spends on the bed. 

Root Cause Analysis

The approach identifies the root cause of problems or faults (Wilson et al., 2013). It involves a series of steps and the first step is identifying and describing the problem. In this case, the problem is the inappropriate diet for the patient based on his cultural beliefs and lack of patient movement by staff, which leads to bedsores. The second step is establishing the timeline within which the problem occurred.  The hospital should evaluate patient records to assess the prevalence of the problem and its historical record since this information is not clear from the case study. The third step is differentiating between the problem’s root cause and other causal factors. The healthcare facility may investigate the various factors that are responsible for the issues and determine the main factor that can be directly linked to the problems facing the organization. The root cause of the problem is negligence by kitchen staff and negligence by nurses when providing healthcare services. The last step is establishing a causal graph between the problem and root cause. The hospital should create a graph that links negligence by kitchen staff and nurses by establishing how these medical errors impact patient outcomes. 

FMEA Process

Failure Mode and Effects Analysis is a strategy that applies a series of steps to resolve design problems within organizational processes. It applies steps that include the problem definition, and in this case, the problem is the error in dispensation of diets to patients as well as negligence by staff on patients at the bedside. The second step is assembly of cross-functional teams, and in the case study, it should involve the mobilization of teams that will address the problem identified (American Society for Quality, 2019). Some of these include a training team that will train staff members on proper diet dispensation and care for bedside patients, and a supervisory team that will evaluate how staff dispenses diets and care for patients at the bedside. The third step is description of the process, and the hospital should develop a diagram or flow chart that describes the problem and its consequences. The consequences of the problem include poor patient outcomes and the risk of legal liability from staff negligence. The fourth step is applying the vertical approach which is a top-down solution that addresses each of the problems (American Society for Quality, 2019). The organization should start with addressing staff negligence in treatment of the patients at the bedside and the management should implement proper training and supervision to handle this problem. It should use the same strategy to then address the problem of errors in dispensation of diets to patients. Finally, the last step is the determination of outcome measures and actions. Actions will be discussed in the improvement plan while outcome measures include improved patient outcomes, reduction of medical errors and enhancement of the quality of care to patients. 

FMEA Table

Steps in the improvement plan processFailure Mode
Occurrence of CauseA. Severity

Rate 1-1010=Most severe
B. Likelihood of Occurrence
Rate 1-1010=Highest Probability
C. Likelihood of Detection
Rate 1-1010=Lowest Probability
Risk Priority Number
(AXBXC)

Patient orders chopped meat
Erroneous patient dietPoor staff trainingLack of staff supervisionLack of technological tools9
7

8

504
The patient is immobilized on the bed for long time periodsLack of exercise for immobile patients
Poor staff trainingLack of staff supervision

8


8


9


576

Improvement plan, system quality tools and recommendation

Based on these analysis tools, it is clear that Mr. J. is receiving a poor quality of care. The nursing quality indicators have revealed that he is dissatisfied with the care he receives. The root cause analysis may be applied to the situation to investigate the major causes of poor service at the hospital. The FMEA process can also be used to determine the breakdown of processes that have led to errors in diet and nurse neglect of patients. Moreover, Lewin’s change theory can be applied during the implementation phase that will be discussed below. 

The hospital should address weaknesses in the diet systems to ensure that proper diets are dispensed as per the patients’ needs.  There are various recommendations that should be integrated in the improvement plan.   The first is that the hospital should upgrade technology used to dispense food to ensure that human error does not occur when dispensing food to patients. The integration of electronic health records may help in attainment of this goal. The second recommendation is that the hospital should implement strict controls over the kitchen staff, including more supervision to reduce negligent actions by staff in the dispensation of food. To address weaknesses in nursing care, the hospital should retrain nurses on how to give professional services that are consistent with their ethical code. It should enrol them in a training course that also teaches them how to handle immobilized patients to reduce the risk of bedsores. Finally, the hospital should implement strict control over nurses who cater for patients at the bedside to reduce the risk of negligence by staff. 

Application of Lewin’s Change Theory to Improvement Plan

According to the Mind Tools Organization (2019), Lewin’s change management model outlines three steps in implementing organizational change. The first step is unfreezing and entails preparation of the organization for change by explaining the importance of changing the status quo. The second step is change and it involves embracing a new way of doing things and transitioning into the changes that are being implemented. The third stage is refreezing and it is concerned with integrating the changes into the organizational culture and institutionalizing the changes. In applying the change to the hospital, the first step is unfreezing. Management should sensitize staff on the adverse consequences of negligence when either dispensing diets to patients or catering to the needs of patients at the bedside.  These consequences include poor patient outcomes and legal liability that may arise from acts of negligence. This step will prepare them for change. The second step is change, and it should involve the implementation of recommendations contained in the improvement plan. Some of these include staff training on diet dispensation and handling bedside patients, and implementation of quality control interventions such as strict staff supervision to address cases of negligence. Once staff has mastered proper care for patients, the third step will be refreezing.  Once nurses have appreciated the need for change and have been trained, they will maintain high-quality care to patients as part of the hospital’s culture. 

Intervention Testing and Nursing Leadership

To test the effectiveness of the interventions that have been implemented, there are various strategies that can be used. The first is seeking staff and patient feedback through use of anonymous surveys. Patients can give feedback on the quality of care they received in terms of diet dispensation and care at the bedside. Staff can give feedback on the adequacy of training they received, the availability of IT tools to help in diet dispensation and the levels of supervision regarding their work. Another form of intervention testing is analysis of patient data including health outcomes of patients at the bedside and the numbers of medical mistakes after interventions have been implemented. Enhanced patient outcomes and reduction of medical errors will prove that the interventions are effective. 

Nurses should show leadership through being active participants of the change process in the institution. They should acquire the necessary training needed to provide care at the bedside, and apply the ethical principles that guide nursing practice when caring for patients. For instance, nurses should implement the principle of beneficence which entails protecting the welfare of patients through providing the highest quality of care. Nurses should also demonstrate leadership by using evidence-based studies on caring for patients at the bedside, when making decisions that affect patients under their care. 

References 

American Nurses Association. (2007).Nursing sensitive Measures. Retrieved from 

https://www.ncvhs.hhs.gov/wp-content/uploads/2014/05/070619p8.pdf

American Society for Quality. (2019). Failure Mode and Effects Analysis. Retrieved from 

https://asq.org/quality-resources/fmea

Mind Tools Organization. (2019). Lewin’s Change management Model. Retrieved from 

https://www.mindtools.com/pages/article/newPPM_94.htm

Wilson, P. F., Dell, L. D.& Anderson, G. F. (2013). Root Cause Analysis: A Tool for Total  Quality Management. Milwaukee, Wisconsin: ASQ Quality Press

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