Root Cause Analysis
Change in Theory and Improvement Plan
Change theory is a process that includes 3 key components to change a practice. The first is unfreezing, which is where providers need to be open to doing things differently. The transition plan is the implementation of new policies and processes. The third is freezing, which is where the new process is monitored and evaluated for effectiveness.
The first step in the improvement plan is to unfreeze the hospitals current processes. This can be done by involving associates in a plan to change. Having their input on a process change helps them to be more open to the change because they are taking ownership. In this case the issue was inadequate staffing during a high volume and high acuity time. Gathering data and evaluating the need for staffing during different times of the day and night would have to done. The transition plan could involve developing a staffing grid for the acuity and volume of patients. Evaluating the data and revising the process to ensure safe patient care would be imperative. The final step is freezing the process by making it policy. This would have to be monitored continuously