NURS 8300 Organizational and Systems Leadership for Quality Improvement

In week 9 the case study team assumes full senior leader support on the validation of the two
root causes identified.
1. Review the literature to find at least 4 peer reviewed research studies which evoke
validation of the latest patient safety evidence in support of your root cause finding (Only locate 1 peer-reviewed article).
2. At this point, the case study team determines recommendations using the latest
evidence from the literature on what is needed within these two hospitals to address
these significant root causes.
3. Assume a three-month implementation timeframe, recognizing that full realization may
take longer.
4. Construct a straw man Gantt chart or project plan to capture all necessary components
to move the recommendations forward.

Case Study Weeks 8 & 9 Peri-operative Services in major medical centers

You are the Director of Peri-operative Services overseeing surgical services in a multi-hospital system in the Midwest United States. Your organization has 15 major medical centers in the system as well as 26 same day surgery centers, rehabilitation centers, long term care settings, and outpatient clinics. In short, your system is a fully integrated delivery of care network (IDN). You are fairly new in your role, and you have been asked to lead an initiative to assemble a parsimonious set of metrics that link to your organization’s strategic plan. You have had numerous metrics on your dashboard for years. But developing a balanced scorecard for your service line is a new concept for you. In managing these services for several years (but in a lower level position), you were at the helm in instituting a universal protocol throughout your IDN. Compliance to that universal protocol is monitored carefully, primarily by auditing the checklist used to collect evidence in the “sign off” that the universal protocol has been completed. In fact, compliance to the universal protocol has indeed been tracked by your hospitals and surgical centers for years, and this data appears on your dashboard. Compliance with patient identification procedures is also comprehensive, with ongoing data collection on these important processes. Compliance has been strong, never dipping below 100% in a given month, quarter or year, in any of your centers for both patient identification, and the universal protocol. This notwithstanding, in the past 3 months you have seen the incidence of serious errors occurring within your surgeries. Two incidents come to mind. While both are evidence of a serious breach in patient safety, one had serious consequences to the patient; the other did not, however, it was still significant enough to warrant a closer look at your processes.

1. Mr. P. G. Green was a patient of Dr. Black’s in one of your surgi-centers. He was scheduled for a laparoscopic cholesystectomy at 10:00 am. K. E. Underwood was a patient of Dr. Brown’s and was also scheduled for a laparoscopic cholesystectomy at 10:30am. Drs. Brown and Black are colleagues but not within the same practice. It wasn’t until about 15” into the actual procedure when the team realized that Mr. Green was being operated on by Dr. Brown and not Dr. Black. He proceeded to complete the procedure, as patient Underwood was being prepped in the next room. Upon examination of the universal protocol checklist in Dr. Brown’s room, all criteria were documented as “completed”. All signatures were in place indicating that patient identification was evaluated, checked and double checked.

2. Patient White has been diagnosed with lung cancer within the past 45 days. He’d been seen in Dr. Mellow’s office, had outpatient radiologic procedures, and underwent a biopsy in recent days, which indicated significant invasive carcinoma, but localized to one area of his right lung. Mr. W. agreed to have one lobe of his right lung removed. All preoperative work was completed in a satisfactory manner. The patient was properly prepped in the OR, and the surgery proceeded. The universal protocol was adhered to, but about halfway through the procedure, it appeared that healthy tissue was being extracted. It was discovered that the surgeon had removed the lower lobe of the left lung, leaving the carcinoma in place and removing healthy tissue.

Two root cause analysis (RCA) teams have been constructed, at each of the organizations that experienced each event. The events are significantly disappointing. Up until this point in time, the leadership of the system had been confident that patient safety was being protected across their member organizations. They have been studying these events and their processes to learn how to prevent similar events from re-occurring. The CNO for each medical center serves on each team along with Chief of Surgery and CMO. One physician’s assistant (PA) from the highest volume practice participates. Two prominent RNs who are “informal leaders” in the OR suites have pledged full participation. Chief surgical residents in each medical center are fully engaged. As the system Director of Peri-operative services, you have served as “process owner” for both teams, and the VP for Quality has provided facilitation skills to each team. Attendance at team meetings has been spotty, but the team set ground rules at the beginning of their process and every time attendance has fallen off, the CEO (the RCA team’s executive sponsor) steps in and reaffirms the value of the team process and removes barriers to participation. The Lean Six Sigma model has been loosely applied. The VP for Quality holds a black belt, and you hold a green belt. Recognizing that these two events were distinctly different, similar issues emerged over the course of the RCA. Consequently, data, information and findings were shared across each team through the team leader (business process owner) and facilitator (VP for Quality). Teams have completed the RCA process and identified contributing factors. Teams are about to share their processes and present their findings. While each team worked independently, their processes and outcomes were largely very similar. They have included a selection of the tools that they have used, including process flow chart, cause effect diagram and have tested theories related to these (see attached), and are about to draw conclusions about the root causes.

Data summaries:

a. Bar graph entitled: “Training in Peri-operative procedures: Timeout and Universal Protocol”. The graph shows on the y axis the % compliant with new hire and annual training across 15 hospitals and 26 surgi-centers and are “rolled up” over a five year period of time ending in 2010. Scores are very high are seldom dip below 98-100% compliant. This measurement mechanism appears both on the peri-operative services dashboard and on the systems balanced scorecard.