Case Study Part 2

SECTION IV BACKGROUND: CLARIFYING THE PROBLEM

The intent of this section is to work through the causative factors to fully understand the clinical problem. The focus

is to use a root cause analysis approach to examine the big picture and pull out the factors that contribute to the

problem.

In this section, you will use information provided from previous sections of the case study and your research to

create a root cause analysis. If needed, create scripts from the perspective of the various stakeholders who might be

involved with the process being investigated to illustrate the various perspectives.

Use the Healthcare Quality Improvement Partnership’s Root Cause Analysis for Clinical Audit guide (accessible at

www.hqip.org.uk/resources/using-root-cause-analysis-techniques-in-clinical-audit/) to guide the students through a

root cause analysis. Complete the cause–effect or fishbone diagram. A resource that includes a fillable template for

creating a cause–effect diagram can be accessed through the Institute for Healthcare Improvement (a free account

is required, accessible at www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx).

Chapter 12 Patient Safety includes an example of a root cause analysis.

The clinical nurse specialist (CNS) decides to work through a root cause analysis and use a cause–effect

diagram (fishbone diagram) with the team to identify potential causes for catheter-associated urinary tract

infections (CAUTIs). You work with the CNS to complete this activity with the team.

SECTION V BACKGROUND: PLANNING FOR CHANGE The intent of this section is to create a preliminary plan for action by using the PLAN-DO-STUDY-ACT model as

outlined in chapter 13.

The team decides to use the Plan-Do-Study-Act model to determine small tests of change that can be undertaken to

improve CAUTI’s in the patients the team cares for. You work with the team to develop a map of the PDSA model.