Review COS materials first: use success guide
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- Task 2 Overview: Competencies, Introduction, Scenario, Requirements, Rubric
- Skim pages 12-20 in C489 Course Materials > Units 3 & 4
- Access IHI Patient Safety: Root Cause and Systems Analysis Summary Sheet– Course Materials > Unit 3 > page 14 (RCA guide) – A A1 and A2 success guide has task 2 template
- Access FMEA tool and FMEA table attached to your task directions
- Prepare to write
- Be sure you are writing to the Task Requirements and then verify with the Task
- Watch Understanding Task Directions
- Utilize the SAT Task 2 Template
- Recommended length 10-12 pages
| Task | Helpful Tips |
| A. General Purpose of RCA | 1. Use the RCA guide also see IHI PS 201 – Lessons 2 & 3 Course Materials> page 14
2. Describe in your own words 3. Do not need to apply steps to the scenario in this section |
| A1. RCA Steps | 1. List each of 6 step briefly and describe in your own words
2. Do not need to apply steps to the scenario in this section |
| A2. Apply RCA | 1. Define causative and contributing factors (either together or separately) that lead to sentinel event outcome
2. Causative factor – lead to patient’s death 3. Contributing factor may not have had significant impact by itself 4. List several factors for each 5. No right or wrong answers as long as evidence is cited from the scenario 6. List which steps from the RCA process helped you determine these factors (not all steps need to be listed; just the steps that helped determine causative and contributing factors). |
| B. Propose Process Improvement Plan
Decrease likelihood of scenario Create implement modify or change |
1. Based on the problems you identified in section A2, what recommendations would you make to correct those problems?
2. Think about what you could create, implement, modify, etc. to prevent the outcome in the scenario education staff equipment etc
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| B1. Lewin’s Change Theory
Each phase applied to proposed improvement plan How human beings react when change introduced into organization
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1. See Cherry (textbook) Ch 17- page 304 or IHI QI 201: L1: How Change Spreads from Course Materials > page 19
2. Describe Lewin’s Change Theory and the 3 phases 3. Discuss how you would apply the 3 phases within your improvement plan (from letter B) |
| C. FMEA Process
General purpose FMEA in my own words FMEA as defined by IHI Describe steps as someone reading knows IHI |
1. Use the FMEA Tool Also Watch the FMEA video from Course Materials > page 15
2. Put information in your own words |
| C1. Steps of FMEA process | 1. Use the FMEA Tool Also Watch the FMEA video from Course Materials > page 15
2. Describe the 5 steps of the FMEA process as defined by IHI. 3. List as though someone reading your paper would know how to conduct an FMEA 4. There are 5 steps in the FMEA process according to IHI; completing the FMEA table is Step 4. A numbered list can be used. |