Explain How the Fundamental Accoungting Concepts Are Used in Preparing Financial Statement Essay Example

Explain How the Fundamental Accoungting Concepts Are Used in Preparing Financial Statement Essay Explain how the fundamental accoungting concepts are used in preparing financial statement. Use examples to illustrate the application of the fundamental accounting concepts. Accouting is the language of business and it is used to communicate finance information. In order for that information make sencse, accouting is based on 10 fundamental concepts. These fundamental concepts then form the basic for all of the Generally Accepted Accouting Principles (GAAP).And these are 10 fundamental concepts:the Business Entity Concept, Monetary Concept, Historical (Cost) Concept, Going Concern Concept, Dual Aspect Concept, Accrual Concept, The relisation Concept, Consevatism, Consistency, Materially In those fundamental accounting concepts above which I would apply and explain for 6 fundamantal accouting concept below which I think they are used in preparing the Financial Statements: 1. Going concern: -According to Dyson (2006) The going concern concept implies that the business will continue to operate for the fore-seeable future.It means that it is considered sensible to keep to the use of the historical cost concept when arriving at the valuation of assets. And if the business decides to liquidate or become bankrupt then a different approach to valuation is required. -This value includes the liquidation value of a companys tangible assets as well as the present value of its intangible assets (such as goodwill). The going-concern value is worked into the purchase price of a company, and is the main reason why the purchase price of a company tends to be higher than the current value of the assets of the company.For example, the liquidation value of Widget Corp. is $10 million. This sum represents the current value of inventory, buildings and other tangible assets that can be sold assuming that the company is completely liquidated. However, Widget Corp. s going-concern value could very well be $60 million, as the companys reputation of being the worlds leading widget produ cer and its ownership of patents and associated rights for widget production mean that the company should have a large steady stream of future cash flows. 2. Accrual concept When preparing the profit and loss account, revenue and profits, and matched with the associated costs and expenses incurred in earning them. This means that revenues and expenses are recognized when they are incurred rather than when the related cash is received or paid. Accrual of income is always measured over a period of time which is normally the accounting year. Expenses are costs incurred in earning revenue. Those expenditures which may be charged against revenues for a period will be considered as operating expenses.The accrual concept is applied both in ascertaining the revenues for a period and ascertaining the expenses to be charged against the revenues. For example if   a business has a year end of 30th June 193 and there had been an electricity charge of ? 60 for the six months to the end of Decem ber 192 , ? 30 for the quarter ending 31 March 193 , and an estimate of ? 20 has been made   for the quarter ending 30 June 193 . The amount charged in the profit and loss account for the year end 30/06/x3,   will be the charge for the 12 months ? 110, i. e. ?60 + ? 30 + ? 20. This estimate of ? 20 for the March/June quarter is known as an accrual. . Monetary Concept: -Accounting uses money to express certain facts of a business and they can show a expression of the wealth of the business. 4. Consistency concept: There should be consistency of treatment of like items within each accounting period and from one period to next. In other words, once you have chosen an accounting treatment, you should stick with it from one year to next.. It helps the user to make comparisons over time, and so to pick out useful trends. Without consistency we cannot have comparability; and without comparability, financial reporting is rather meaningless.For example, a profit for the year of ? 100m m ay initially be perceived as good, but can only really be assessed by comparison with last year and/or budget for this year. Finally, it must be noted that the consistency concept does not preclude changes being made. Clearly, as time goes by, new accounting practices will develop. However, as these are adopted two things must happen. First, they must be fully disclosed as a change in accounting policy. And second, the comparative figures for the previous year must be restated under the new policy so as to facilitate comparison. . Materiality: -A very small mistake in the financial statements of an entity will not invalidate those statement . They should still be usable by anyone interested in entity. However, the key issue is obviously what we mean by ‘very small’. The concept of materiality applies the test of whether the financial statements still show a true and fair view. The consistency concept says that when a business has once fixed a method for the accounting t reatment of an item, it will enter all similar items that follow in exactly the same way. 6.Dual Aspect Concept -All business events are regarded as having a dual aspect. In all business transaction involves two entries, a debit entry and a credit entry. Each transaction involves two entries, a debit entry and a credit entry. Every debit must have a corresponding credit, the total debits must at any time equal the total credits. Whether this be so or not is easily ascertained by means of Trial Balance. 2. Critically evaluate the role of financial accouting in aiding the decision making processes of 4 different non-management stakeholder group.Your anwers should include an explanation of the nature of the decisions each of the stakeholders are likely to be taking in relation to their interactions with a business. I would chose 4 different non-management stakeholder groups below to critically evaluate the role of financial accouting in aiding the decision making processes: Investors: Investors are the people who invest the money for business so they are concerned about risk and return in relation to their investment. So they require informaiton to decide whether they should continue to invest in a business.They also need to beable to assess wether a business will be able to pay diviend, and to measure the performance of the business management overall. The key accouting information for an investor is therefore: -Information about growth-sales, volumees -Profitability (profit margins, overall level of profit) -Investment (amount invested, essets owned) -Comparative informmtion of competitors Lenders Lenders are the people who lend money in a business as : banks and loan stokholders so they require information that helps them determined whether loans and interest will be paid when due.The key accouting information for lenders is therefore: -Cash flow -Security of assets against which the lending may be secured -Investment requirements in the business Creditors Sup pliers and trade creditors requirement information that helps them Understand and assess the short-term liquidity of a business. They need to know is the business able to pay short-termdebt when it falls dua? Creditors will, therefore,be looking for information on: -Cash flow -Management of working capital -Payment policyThe purpose of financial accounting statements is mainly to show the financial position of a business at a particular point in time and to show the how that business has performed over a specific period. There are three important elements of finance accounting statement : the profit and loss account for reporting period, a balance sheet for the business at the end of the reporting period and a cash flow statement for the reporting period. Government and taxes department: They need to know about the information of Financial Statements of all the company or business who is running the business legal.There are many agencies and departments that are interested in accoun ting information. And through Financial statement they can know the profit the business make to levy taxes. The Inland Revenue needs information on business profitability in order to levy and collect Corporation Tax. Customer excise need accounting in formation to verify Value Added Tax (â€Å"VAT†) returns; local government needs similar information to levy local taxes and rates. Some agencies(e. g the Competition Commission and the Environment Agency) need information to support decisions about takeover and grants . for example investment analysts are an important user group-specifically for companies quoted on stock exchange. They also require very detailed financial and other information in order to analyse the competitive performance of a business and its sector. (1539 words) Explain How the Fundamental Accoungting Concepts Are Used in Preparing Financial Statement Essay Example Explain How the Fundamental Accoungting Concepts Are Used in Preparing Financial Statement Essay Explain how the fundamental accoungting concepts are used in preparing financial statement. Use examples to illustrate the application of the fundamental accounting concepts. Accouting is the language of business and it is used to communicate finance information. In order for that information make sencse, accouting is based on 10 fundamental concepts. These fundamental concepts then form the basic for all of the Generally Accepted Accouting Principles (GAAP).And these are 10 fundamental concepts:the Business Entity Concept, Monetary Concept, Historical (Cost) Concept, Going Concern Concept, Dual Aspect Concept, Accrual Concept, The relisation Concept, Consevatism, Consistency, Materially In those fundamental accounting concepts above which I would apply and explain for 6 fundamantal accouting concept below which I think they are used in preparing the Financial Statements: 1. Going concern: -According to Dyson (2006) The going concern concept implies that the business will continue to operate for the fore-seeable future.It means that it is considered sensible to keep to the use of the historical cost concept when arriving at the valuation of assets. And if the business decides to liquidate or become bankrupt then a different approach to valuation is required. -This value includes the liquidation value of a companys tangible assets as well as the present value of its intangible assets (such as goodwill). The going-concern value is worked into the purchase price of a company, and is the main reason why the purchase price of a company tends to be higher than the current value of the assets of the company.For example, the liquidation value of Widget Corp. is $10 million. This sum represents the current value of inventory, buildings and other tangible assets that can be sold assuming that the company is completely liquidated. However, Widget Corp. s going-concern value could very well be $60 million, as the companys reputation of being the worlds leading widget produ cer and its ownership of patents and associated rights for widget production mean that the company should have a large steady stream of future cash flows. 2. Accrual concept When preparing the profit and loss account, revenue and profits, and matched with the associated costs and expenses incurred in earning them. This means that revenues and expenses are recognized when they are incurred rather than when the related cash is received or paid. Accrual of income is always measured over a period of time which is normally the accounting year. Expenses are costs incurred in earning revenue. Those expenditures which may be charged against revenues for a period will be considered as operating expenses.The accrual concept is applied both in ascertaining the revenues for a period and ascertaining the expenses to be charged against the revenues. For example if   a business has a year end of 30th June 193 and there had been an electricity charge of ? 60 for the six months to the end of Decem ber 192 , ? 30 for the quarter ending 31 March 193 , and an estimate of ? 20 has been made   for the quarter ending 30 June 193 . The amount charged in the profit and loss account for the year end 30/06/x3,   will be the charge for the 12 months ? 110, i. e. ?60 + ? 30 + ? 20. This estimate of ? 20 for the March/June quarter is known as an accrual. . Monetary Concept: -Accounting uses money to express certain facts of a business and they can show a expression of the wealth of the business. 4. Consistency concept: There should be consistency of treatment of like items within each accounting period and from one period to next. In other words, once you have chosen an accounting treatment, you should stick with it from one year to next.. It helps the user to make comparisons over time, and so to pick out useful trends. Without consistency we cannot have comparability; and without comparability, financial reporting is rather meaningless.For example, a profit for the year of ? 100m m ay initially be perceived as good, but can only really be assessed by comparison with last year and/or budget for this year. Finally, it must be noted that the consistency concept does not preclude changes being made. Clearly, as time goes by, new accounting practices will develop. However, as these are adopted two things must happen. First, they must be fully disclosed as a change in accounting policy. And second, the comparative figures for the previous year must be restated under the new policy so as to facilitate comparison. . Materiality: -A very small mistake in the financial statements of an entity will not invalidate those statement . They should still be usable by anyone interested in entity. However, the key issue is obviously what we mean by ‘very small’. The concept of materiality applies the test of whether the financial statements still show a true and fair view. The consistency concept says that when a business has once fixed a method for the accounting t reatment of an item, it will enter all similar items that follow in exactly the same way. 6.Dual Aspect Concept -All business events are regarded as having a dual aspect. In all business transaction involves two entries, a debit entry and a credit entry. Each transaction involves two entries, a debit entry and a credit entry. Every debit must have a corresponding credit, the total debits must at any time equal the total credits. Whether this be so or not is easily ascertained by means of Trial Balance. 2. Critically evaluate the role of financial accouting in aiding the decision making processes of 4 different non-management stakeholder group.Your anwers should include an explanation of the nature of the decisions each of the stakeholders are likely to be taking in relation to their interactions with a business. I would chose 4 different non-management stakeholder groups below to critically evaluate the role of financial accouting in aiding the decision making processes: Investors: Investors are the people who invest the money for business so they are concerned about risk and return in relation to their investment. So they require informaiton to decide whether they should continue to invest in a business.They also need to beable to assess wether a business will be able to pay diviend, and to measure the performance of the business management overall. The key accouting information for an investor is therefore: -Information about growth-sales, volumees -Profitability (profit margins, overall level of profit) -Investment (amount invested, essets owned) -Comparative informmtion of competitors Lenders Lenders are the people who lend money in a business as : banks and loan stokholders so they require information that helps them determined whether loans and interest will be paid when due.The key accouting information for lenders is therefore: -Cash flow -Security of assets against which the lending may be secured -Investment requirements in the business Creditors Sup pliers and trade creditors requirement information that helps them Understand and assess the short-term liquidity of a business. They need to know is the business able to pay short-termdebt when it falls dua? Creditors will, therefore,be looking for information on: -Cash flow -Management of working capital -Payment policyThe purpose of financial accounting statements is mainly to show the financial position of a business at a particular point in time and to show the how that business has performed over a specific period. There are three important elements of finance accounting statement : the profit and loss account for reporting period, a balance sheet for the business at the end of the reporting period and a cash flow statement for the reporting period. Government and taxes department: They need to know about the information of Financial Statements of all the company or business who is running the business legal.There are many agencies and departments that are interested in accoun ting information. And through Financial statement they can know the profit the business make to levy taxes. The Inland Revenue needs information on business profitability in order to levy and collect Corporation Tax. Customer excise need accounting in formation to verify Value Added Tax (â€Å"VAT†) returns; local government needs similar information to levy local taxes and rates. Some agencies(e. g the Competition Commission and the Environment Agency) need information to support decisions about takeover and grants . for example investment analysts are an important user group-specifically for companies quoted on stock exchange. They also require very detailed financial and other information in order to analyse the competitive performance of a business and its sector. (1539 words)

Strangles Prevention essays

Strangles Prevention essays Strangles is a highly contagious infection that plagues horses, and it needs to be controlled. The transmission of strangles is very easy, and its effects on horses are very serious. Vaccines should be required for all horses. Measures need to be taken to control the spread of strangles immediately. Strangles is the common term for streptococcus equi bacterium (Small). The name strangles comes from the effects of the bacteria. The streptococcus bacteria cause abscesses in the throat of a horse(Kunz). These abscesses grow so large they cut off the trachea and strangle the horse(Kunz 1). Infection in one to five percent of cases may spread to other organs of the body(Kunz 1). The infection of other organs is called Bastard Strangles (Prescott 2). This type of strangles can create a brain abscess that has the potential to rupture, which would cause immediate death in a horse. The Animal Health Trust states, The disease (strangles) can be severe and prolonged with up to ten percent of cases dying of complications,(Chanter 1). A horse may build up immunities to strangles, but first it has to contract the bacteria. Of the horses that do contract the strangles bacteria 25 percent do not develop the immunity to the bacteria (Equivac 1). Horses can contract strangles a number of ways. Foals are especially high at risk. The main distribution of the bacteria is by nose discharges and burst abscesses, therefore anything an infected horse is in contact with has the bacteria (Small 1). The Streptococcus Equi bacteria is hardy and can live in straw for months and on any other object for periods of time (Horses in the News 4). This leaves farms with horses traveling in and out and any other horse recreation susceptible to a strangles outbreak. The complications of strangles causes a serious problem in the horse world. Poor horse management is to blame. There is a vaccine available to ...

Perception and Decision Making Essay Example | Topics and Well Written Essays - 500 words

Perception and Decision Making - Essay Example Based on the case of Armstrong (A), it can be observed he was faced by the three decision problems. The first decision problem was job A. Under this job, Dave Armstrong was supposed to have a large capital outlay. The job also had a lot of untapped potential returns. In addition, Dave perceived that this is a kind of job that he would like to do but his wife was against his idea because it involved a lot of risks. The second job, B, Dave did not like it thought it had better returns. In addition, this job was to last for only two years. The third job, C, was involving though it had better returns compared to A and B (Steven, paras.3-6). Based on this case, it can be observed that perception may be affected by the situation under which one is operating in. The situation may in turn affect the cause of action to be undertaken. For instance, if among the three jobs could mean perceived losses will be incurred; Dave Armstrong may make his decision based on the situation he was going thro ugh. Whereby, they make an optimal decision that will remedy the situation based on their perception. Secondly, perception may be affected by the person interest, motives, experience and attitude and anticipation. PROACT approach may be used to analyze Dave Armstrong decisions. The first element in this approach involves problem identification and making right decision based on that problem. The second element entails objective definition, this involve gathering the necessary information and determining the right course of action (Steven, paras.1-5). The third element of PROACT approach entails evaluating the three alternatives prior making the right choice. The forth element entails determining the consequences of each course of action that Dave is looking forward to undertake. The fifth element entails evaluating the trade-off between the various objectives available.

Literature's Power To Tell History Essay Example | Topics and Well Written Essays - 3750 words

Literature's Power To Tell History - Essay Example Written works that can be preserved through the ages and as such are able to be placed in the hands of countless people, all the while giving each and everyone an image(s) that will, in one way or another, cement for them in their mind an idea(s) that would have seemed to be improbable to them had they not have read what it was they read at the time that they had done so. As journalists, this task remains in the forefront of importance when it comes to the production of articles on issues pertaining to human interest and relevance. From a journalistic standpoint, the work of John Hersey remained true to the central role of that which a journalist is intended to do. Another figure to consider is that of Tom Wolfe, who also was a journalist during his career. In regards to his views on the idea of 'new journalism', Wolfe's personal definition would be as such, "Wolfe described his version of the New Journalism as an appropriation of the techniques of realistic fiction writers, building a nonfiction account of a person or group after an intense period of observation and interviews, mixing exposition with reconstructed dramatic "scenes" that rely upon dialogue and access to the interior experience of the subjects," Adding that, "Wolfe experimented with a flamboyant style, switching freely between the point of view of the narrator and his subjects, employ ing an energetic vocabulary that mixed the subject's colloquialisms with his own vivid and esoteric diction, and constructing a detailed awareness of the subject's social status. At its best, the New Journalism opened a new world to nonfiction writing, both enriching the reader's sense of the lived experience of the subject and expanding the range of interpretation open to the writer, whose voice had an entirely new range," ("Tom Wolfe", p.1). Such a practice would bode well for literary understanding of times and events that have occurred in the past or the present. By nature, human beings often gravitate towards that which they themselves have felt or experienced before in their own lives. Utilizing scenes of human intrigue and condition, rather than primarily a resuscitation of historical fact, give way to a stronger reliance upon the ability to empathize with that which can be identified with through personal circumstance. The usage of first-person narrative serves to guide the reader through the events that occurred in such a way that they themselves can feel as if they are experiencing the events firsthand with their own eyes. Such an experience that remains true to the purpose of the journalistic endeavor. To have the reader, while reading the written compilation of the author, be able to observe the events of history through means of first person narrative and the consumption of details having to do with the daily behavior patterns, falls squarely within the clearly defined definition of journalism, or in this case "new journalism". As for New Journalism, "In Wolfe's hands, the New Journalism was a celebration for life as lived, and at the same time an instrument for the disparagement of pretension and self-destructiveness. In his story on Junior Johnson, a race driver schooled in back-country whiskey running, Wolfe described an escape for revenue agents: "They had the barricades up and they

Case Study Example of Reflective Listening in Counselling

Case Study Example of Reflective Listening in Counselling Case: Savita is a 33 year old woman. Her marriage broke up more than 10 months ago. Prakash and Savita had been married for ten years, and had two children, Rakesh aged 6 and Rohan aged 18 months. Currently both children are with Savita. Savita came for counselling after being referred by her Family Doctor who thinks she has early signs of depression. Background Savita and Prakash met in college where they were studying BCS. After graduating they both worked in separate companies and were dating for many years before getting married. Savita continued her job after marriage until the birth of their first child Rakesh, Savita took a break and to work part time. Prakash worked full time and received a number of promotions. Savita was working part time until the birth of their second child Rohan, then she again took a break to look after both her children. She got a new job and was about to start to work when one day Prakash shocked her by informing her that he was leaving her for another woman who worked at his office. A month later Prakash moved out of their home. He has not contacted Savita or the children since then. Savita has too depressed to return to work and is now in danger of losing her job with the company. Session Details Upon Savita’s arrival, the Counsellor spent some time developing speaking to Savita to make her feel comfortable and at ease. Counsellor began the session by asking Savita whether she had any questions about the counsellor and answered them about her experience and work in counselling. Counsellor proceeded to ask Savita what had brought her to counselling. Savita kept staring at the floor and after a few seconds started crying, â€Å"My husband left me. He likes another woman; I just can’t get over it.† Counsellor responded with a paraphrase and reflection of feeling â€Å"You sound devastated by the behaviour of your husband Savita.† Savita replied â€Å"Yes I am, but it was many months ago, I should get on with my life. I don’t know why I am still so upset. My family and friends are saying that I have to move on. But I miss Prakash so much and the children cry for him every day.† Counsellor: â€Å"So, you and the children are still very sad and yet your family and close friends think that it is about time you started living again?† Savita: â€Å"Yes, maybe I am taking too long to get over him. What do you think?† Counsellor: â€Å"Let me ask you Savita. Do you think six months is long enough for your sadness about your marriage?† Savita: â€Å"No I don’t.† Counsellor: â€Å"And you’re the only one knows how you are feeling and whether you can get over your marriage with Prakash, Savita.† Savita continued her story about her life with Prakash and how she has struggled for the last ten months without Prakash. Savita described the traumatic situation and how she is has looked after the children on limited income. She also spoke about her fears and uncertainty about her own and her children’s future. Counsellor focused on Savita to encourage her to speak about her feelings and her pain. Counsellor summarized Savita’s issues and said â€Å"Savita, you’ve just described a very traumatic time in your life you must have had to make a lot of adjustments to your life during this time. You have the responsibility of two children, you have to take care of the house and manage your finances. At the same time you are facing a lot of pain with regard to your marriage. That is quite a lot that you are managing in your life right now. † Savita: â€Å"Yes, my situation is very bad. It didn’t seem so bad when Prakash was living with us.† Savita cried a lot and told the Counsellor about her childhood dream about getting married in a joint family how they show on TV and in the romantic Yash Johar family movies. She continued to cry about how she will never be able to fulfil that dream. She also spoke about her feelings of anger and blamed herself for not being able to deal with her situation and be a good parent. Through open questions, paraphrases and thoughts, Counsellor was able to help Savita her feelings of anger and also helped he understand what being a ‘good mother’ meant to her. Savita spoke about her own mother who was a stay at home full time Mom. They also spoke about different parenting lifestyles of the past and today. How the role of women has changed in the Indian society and how friends and relatives are treating Savita. Savita said that she missed her job and the satisfaction it gave her to have a career. Counsellor helped reveal Savita’s feelings and understand what Savita liked about her work and her strengths and capabilities. Savita: â€Å"I am thinking that , maybe I could talk to my organisation to get me to work part time for a while until I can get my life organised a bit better. I have a few family member and friends who might be able to help me out with the children.† Counsellor smiled at Savita and helped her make up her mind for herself and her future. Savita: â€Å"Yes, I will speak to my boss on about it.† Then, Savita’s looked more relaxed and comfortable. Counsellor asked if there was anything else she’d like to talk about today. Looking at her watch said that the children would be waiting for her. She also said that if she needed to talk she would come back. Counsellor replied that she was most welcome and wished her luck. Session Summary In the session, Savita was given the freedom to talk about her pain in a place full of empathy, genuineness and unconditional positive regard. A Case Study 1 Samantha is a 38-year-old Anglo-Indian woman who had abused a number of substances, including cocaine, heroine, alcohol, and marijuana over the past 15 years. She left high school and worked as a prostitute for 5 years. Later she found a job as a sales clerk at a home furnishings store. Samantha had two children in her early twenties, a daughter who is now 15, and a son, aged 18. Because of her substance abuse problems, they lived with other relatives who agreed to raise them. Samantha was in treatment repeatedly and had remained substance free for the last 5 years, with several minor relapses. She had been married for 2 years, to Steve, a carpenter; he was substance free and supported her attempts to stay away from substances. Few months ago she became symptomatic with AIDS. She was diagnosed with HIV-positive for 5 years but had not developed any illnesses related to the disease. Samantha had practiced safe sex with her husband who knew of her HIV status. Recently, after learning from the physician at her clinic about her HIV symptoms, she began to shoot up, which led her back into treatment. Out of fear, she came to visit a counselor at the clinic one day after work who she was asked to meet by her physician. She looked all worried about her marriage and that her husband would be devastated by this news. She was afraid she was no longer strong enough to stay away from drugs since discovering the onset of AIDS. She was also concerned about her children and her job. Uncertain of how she would keep on living, she was also terrified of dying. The counsellor engaged in reflective listening, his words were of acceptance to Samantha and her past, and he clarified her current situation and feelings. He was empathetic of her emotions and feelings and was in complete congruence with her mood and thought flow. As Samantha developed trust in the counsellor, he began to emphasize her positive characteristics and her potential to make meaningful choices to become the person she wanted to (and could) become. The counsellor also helped her develop sufficient insight so that she could make choices that reflect more closely the values and principles to which she aspired. During this time, she mentioned her will to tell her husband about her symptoms and try to strengthen her marriage. During the session, when Samantha began to feel guilty about her past as a prostitute, the counsellor demonstrated appreciation of her struggle to accept that aspect of herself, highlighting the fact that she did eventually choose to leave it. He mentioned that she did the best she could at that time and underscore her current commitment to choose a better life. He counselled Samantha, that she would be supported and accepted, not criticized. She was completely engaged with the counsellor. She expressed her fear of death and the effect this fear had on her. Samantha happened to mention that this was the first time in her life that someone was unconditionally accepting of her or focused on her strengths rather than her failings. What was noticed was that she had the ability to solve problems, which was reflected by her return to counselling and her insight about needing help. She mentioned that by being understood and accepted, her self-esteem and sense of hope begun to increase and h er shame begun to decrease. She had felt supported in making critical choices in her life and more confident to resume her recovery. A Case Study 2 Shashank was a 36 year old man who worked as an admin employee for a small family business. The business was failing and Shashank was worried that he would probably have to begin the process of â€Å"winding it up† in the near future. His commitment to the business and his friends, the business owners, had intensified the level of stress he was feeling as a result of the business collapse. He had taken a week off work on sick leave and felt too â€Å"stressed† to return to work. Revati, Shashank’s wife, had contacted the counselor because she was greatly concerned for her husband. She was worried that Shashank was depressed as he was refusing to go to work. She stated that he had agreed to attend counseling if she organized an appointment, however he did not think it would help him. Shashank attended four sessions with the counselor over a ten week period. Shashank had reported the following symptoms: decreased motivation particularly in relation to his work, unu sual outbursts of anger, anxiety whenever he thinks about his work or attends his workplace, and difficulty sleeping. He stated that these symptoms commenced when he realized that the business he was working for might begin to fold and have increased to the point that he is finding it difficult to complete his usual tasks and â€Å"doesn’t want to do anything†. At the first session, the counselor engaged in reflective listening, his words were of acceptance to Shashank and his situation, and he clarified his current situation and feelings. He was empathetic of his emotions and feelings and was in complete congruence with her mood and thought flow. As Shashank developed trust in the counselor, he began to tell the counselor a lot of facts that were lying deep within him. He told the counselor that he had worked as an admin employee in small businesses for the last twelve years. About eight years ago he was working with another business that required him to close it down . He described that experience as extremely distressful. He felt that the process had involved a loss of loyalty from organizations associated with the business and that he saw this as a â€Å"personal attack† against him. He also felt he had been exposed to people who would do everything they could to get as much as possible from a â€Å"crumbling company†. In the next session, Shashank reported that he felt he was â€Å"depressed† (using his own understanding of the term). He stated that the depression began as the retail business he was working for started deteriorating. During that time he felt betrayed by people he had trusted and he felt â€Å"conned† and tricked by many â€Å"colleagues†, and as a result, he had felt like a failure. He stated that he was now experiencing an extreme fear of having to go through the same experience again. The counselor identified the seriousness of the events that had led to his level of stress and normalized Shashank’s reaction. To manage the current level of stress that Shashank was experiencing, the counselor recommended he continue his temporary respite from work and that he had to implement some relaxation strategies like regular exercise, doing things that he enjoys and things that he finds relaxing. Shashank was very concerned about what he should do about his retu rn to work. He said that he did not feel that he could go back. The counselor suggested that he try not to think about the decision concerning his return to work until the next session which was in two weeks In the following session, Shashank reported that he felt â€Å"more relaxed†, although he continued to feel unmotivated to return to work. He described walking regularly and avoiding worrying too much about work. He also said that he had gone into work for two brief periods during the two weeks and had experienced a high level of stress and frustration when he did, although he reported some comfort from the use of the relaxation methods. The counselor used a four step decision-making model to assist Shashank to come to a decision about his work. Step One: What is the problem? Step Two: What are the options and what are the relevant issues associated with each one? Step Three: What is the best option? Step Four: What do you need to do to implement the best option (include possible contingency plans)? The counselor suggested that Shashank had to develop a written plan for managing and balancing all the aspects of his life (relaxation, enjoyment, hobbies, family relationships, and work) that would be reviewed at the next appointment. In the third session, Shashank explained that he had taken a holiday for a week with his wife and had returned â€Å"refreshed† and with new insights into his life. He also stated that his stress continued to reduce. He described a â€Å"new conviction† to balance his life more. At that point, he felt he might be able to return to the workplace full-time, or he might decide to resign from his position and move to another area to start again. He said that he realised that when he has no clear direction and feels out of control, he gets very stressed. He described these things as the triggers for the stress he has felt in this situation and similar situations in the past. He therefore decided to ensure that he always has a sense of direction and control in the whole of his life by taking the focus away from work. The counselor supported and encouraged his continued self-reflection and determination. This move is based on his decision to balance his life more and he was ex cited about his family’s plans. He had commenced playing a sport with friends one night a week and was walking regularly. He stated that he had realised it would take some time to change his measure of success / failure, however, he would continue to address it.

Organizational Systems and Quality Leadership Essay

A. Complete a root cause analysis that takes into consideration causative factors that led to the sentinel event. (This patient’s outcome) The terms failure analysis, incident investigation, and root cause analysis are used by organizations when referring to their problem solving approach. Regardless of what it’s called there are three basic questions to every investigation: 1. What’s the problem(s)? 2. Why did it happen? (the causes) 3. What specifically should be done to prevent it? (Galley, n.d., ∂ 1) In the case of Mr. J, these were multiple issues that led to and contributed to his unexpected demise after what is usually considered a routinely performed procedure in an emergency department setting. The JCHAO (Joint Commission on Accreditation of Healthcare) defines a sentinel event as â€Å"an unexpected occurrence involving death or serious physical or psychological injury†, (Frain, Murphy, Dash, & Kassai, ∂ 1) and in the case of Mr. B, his death would be considered a sentinel event which would warrant a review by a team of interdisciplinary members of the hospital. In this particular case members of the team would include one or more ED physicians, the RN in the scenario and the LPN, a respiratory therapist, a nursing supervisor, a hospital administrator, the ED nurse manager, a hospital pharmacist, and a risk manager. More staff nurses from the ER could also be involved. A credible and successful root cause analysis will identify all of the elements that contribu ted to the event, an action plan will be developed to prevent the event from reoccurring and ensure that those actions are completed. Action plans should be based on best practices and appropriate standards. (Frain et al., ∂ 10) The scenario presented starts out as what  appears to be an average afternoon shift in a small 6 bed emergency department in a rural hospital. Staffing consisted of one emergency room physician, one registered nurse (RN), on licensed practical nurse (LPN) and a secretary. Due to the size of this particular ER, there appears to be limited staffing and therefore limited resources to handle large volumes of patients and or critical patients. There are two patients already being worked up in the department at the time of Mr. B’s arrival and they are stable, have already been evaluated and they are awaiting further treatment or orders. Mr. B is brought to the ED by private vehicle complaining of left leg and hip pain after losing his balance and falling over his dog. The triage nurse noted that other than the patient displaying tachypnea, his vital signs were otherwise within norm al limits. The patient states his pain level is severe, a â€Å"ten out of ten†, and physical examination finds a shortened left lower extremity with calf swelling and ecchymosis. In triage it is noted that the patients leg is stabilized and he is subsequently moved into a patient room where the admitting RN, Nurse J, takes over and gets a more thorough history of this patient, noting impaired glucose tolerance, prostate cancer and chronic back pain. Mr. B regular medications include Atorvastatin and also Oxycodone for his chronic back pain. The doses and how often he takes these mediations is not provided. Although there is no mention of any radiology studies being performed on Mr. B after his arrival, it is assumed that this was performed before the ER physician completed his evaluation and ordered 5 mg intravenous diazepam to sedate the patient to perform a manual reduction of a dislocated hip. After waiting for 5 minutes, the physician then instructed the RN to administer 2mg of hydr omorphone, a powerful narcotic analgesic. The staff waits five more minutes, after which the physician then instructs the RN to repeat both doses of diazepam and hydromorphone because he is not satisfied with the patient’s level of sedation. It is after these medications are administered that the physician notes patient’s weight and history of opiate use. Five minutes after the last dose of medication is administered a successful reduction of the left hip takes place and the patient remains sedated. The reduction procedure, which initially began at approximately 16:05, ended at 16:30. Although Nurse J is monitoring this patient, she is alerted that EMS (Emergency Medical Services) is bringing in an elderly patient with reported acute  respiratory distress. Nurse J, an experienced critical care nurse, elects to place Mr. J on an automatic blood pressure machine with a pulse oximeter. Although not stated, it is likely that this is a portable machine and is not hooked up to any wall monitors. It does not have continuous EKG monitoring. It does not have end tidal CO2 monitoring. Nurse J then elects to leave the patient in the company of his son with a blood pressure of 110/62 and an oxygen saturation of 92% on the portable machine. The patient is breathing room air and does not have any other monitoring. The ambulance patient has arrived to the department and both the RN and LPN are involved in stabilizing this new arrival and discharging the previous patients as the lobby is now becoming congested with more patients seeking care. There is no mention of anyone suggesting that additional staff should be brought in to help with the load. During this time the pulse oximeter alarm fires off in Mr. B’s room showing at saturation of 85%. The LPN enters the room and resets the alarm and repeats a blood pressure, but there is no mention of the LPN assessing the patient’s respiratory and or mental status. At 16:43, almost forty minutes after Mr. B’s procedure had begun, the son who is at the bedside with him states the monitor is alarming. Nurse J finds a Mr. B in respiratory arrest and a stat code is called. A code team arrives and the patient is connected to a cardiac monitor for the first time. The patient is in ventricular fibrillation, CPR is begun, and according to this scenario he is intubated before he is defibrillated. After thirty minutes of interventions, this patient is resuscitated to a normal sinus rhythm with pulses, but is unable to breathe without a ventilator. He has fixed and dilated pupils and no spontaneous movements. Most likely due to the facility being a small rural hospital, they must transport this patient to a higher level of care, and he is flown out to another facility where the patient was ultimately determined to have brain death and was taken off of life support. A-1 Discuss the errors or hazards in the care in this scenario Causative factors in this scenario appear to include poor staffing to patient ratios, inadequate adherence to hospital policy for moderate sedation, and an obvious lack of communication between peers /coworkers. The human factors point to failure of staff to follow an established protocol, possible  fatigue, possible inability to focus on the task, and a lack of utilizing critical thinking skills. There did not appear to be any equipment problems other than the fact that the appropriate equipment that was available was not accessed. The environmental nature of emergency medicine lends itself to hazards in the fact that a department can go from being quiet and mellow in one moment, to being volatile and hectic the next moment. It is an environment of unpredictability and bestows care to a wider population of patients than any other department in the hospital. Common environmental issues to all emergency rooms can include poor location and accessibility of equipment, overhead paging systems that no one hears, security risks, lighting and space issues, lack of privacy due to patients being placed in hallways and other open areas not designated as patient care areas. Organizational factors may include budgeting limitations, staffing to patient ratios and contingency problems. Dealing with unexpected sick calls, inability to fill those calls, power outages and electronic documentation systems that fail, external environmental disasters, rapid influxes of unexpected patients and the media are all common factors that can disrupt hospital care. Well written policies are a must to guide staff in continuing to provide quality care while minimizing errors and hopefully avoiding sentinel events. Potential hazards and errors can be avoided by learning from the literature and past experiences of other emergency departments. Specific protocols for procedures performed in the ER are developed for this very reason. In the given scenario there is the issue of proper staffing which posed a hazard to the patient who eventually expired. Nurse to patient ratios in this scenario were inappropriate due to the fact that a patient who had received moderate sedation was not closely monitored and ideally should have received one on one nursing care for the duration of his procedure and until he met discharge criteria. This would have been possible had the RN asked for back up which was apparently available. Looking back on the scenario, it was noted that immediately after the joint reduction of Mr. B had been performed, a critically ill ambulance patient had arrived and the RN was responsible for that patient as well. In the emergency department, or any department for that matter, nurses are continually subject to frequent interruptions, the need to multi-task, and reliance on â€Å"work-arounds† because of inadequate systems  support. (Cherry & Jacob, 2011, p. 473) In the case of nurse J, she may have been fixated on completing other tasks, such as stabilizing the ambulance patient, thus distracting her from the ongoing developments with Mr. B. who appeared to be resting comfortably with his son at the bedside. Assuming the patient was safe with a family member, the RN missed the opportunity to reverse the downslide of events that unfolded. Not anticipating the need for additional help is a hazard when staff become overwhelmed but continue to proceed as if help is not needed, because they may be accustomed to being understaffed and working only with what they have. Therefore, this presents the issue of the culture of safety, or lack thereof. It did not appear that there was any organized culture of safety and the communication between staff members appeared to be minimal. Possibly there was an environment of distrust between coworkers, or an intimidating environment in which the RN was afraid to speak up to the ERMD regarding the management of the patient’s pain and sedation. Perhaps the LPN was intimidated by the RN and did not chose to inform the RN of the abnormal vital signs. It appears that inconsistent or absent communication skills among the staff present that day contributed overall to a hazardous situation. And lastly, possible poor training and education of staff creates a hazardous environment and the lack of critical thinking skills demonstrated in this scenario suggests that this is an area that needs to be examined closely at this hospital. There is no mention of what the LPN’s responsibility is in assessing the patient but it is difficult to comprehend how an experienced health care worker in an ER would not investigate a poor pulse oximetry reading further than simply resetting the monitor. Educational requirements and experience of the staff needs to be reviewed and revised by the interdisciplinary team as part of the improvement plan. Errors made in this scenario that contributed to this sentinel event include the fact that there was a specific protocol for conscious sedation and it was ignored. Although Nurse J was ACLS (advanced cardiac life support) certified, and she had completed the hospital’s training module, she did not follow the guidelines in the written protocol which more than likely would have prevented any of this event from happening. Perhaps she did not understand the protocol, perhaps she was accustomed to taking short cuts, or perhaps she was drug or alcohol  impaired. Another possibility is that the nurse was not able to find the online protocol on the hospital portal. Perhaps the portal was difficult to navigate and the policy was difficult to locate. Being under time constraint, a nurse might decide to forgo looking up the policy because it is too time consuming to look for it. Only Nurse J. would be able to provide us with this critical information. It is not clear as to why an experienced critical care nurse with no history of negligence did not follow proper procedure. Other errors include the fact that sufficient monitoring equipment was available and not utilized, including use of supplemental oxygen and possible end tidal CO2 monitoring. Furthermore, no one in the department called for any back up, such as a nursing supervisor or a respiratory therapist to help manage the patient. The ER physician who ordered the medications did not communicate with the nurse before the procedure about the risks associated with this patient, including the patient’s home use of opiates for his chronic pain. Polypharmacy, possible use of supplements, adherence issues, and the potential for adverse drug events all posed potential hazards that needed to be addressed. (Williams, 2002, ∂ 1) The RN did not question the physician about the orders and the physician in turn, did not question the nurse if she had any concerns. There was no â€Å"time-out† procedure performed by the staff, which would have given staff members the opportunity to voice concerns. The doctor also failed to notice that the patient was not being appropriately monitored, and along with the rest of the staff he did not appear to display a teamwork mentality. The key to a successful root cause analysis is to search for answers as to what system errors and failures need to be corrected, and not to pursue blame on any one individual. Individual blame centers around forgetfulness, inattention, or moral weakness. It is punitive. A systems approach examines the conditions under which health care workers work and sets up defenses to avert errors or mitigate their effects. (Cherry & Jacob, 2011, p. 473) The goal is to bring staff together to design and implement processes that provide uniform standards of treatment and care and provide safety to all involved and minimize the likelihood of harm or a sentinel event. B. Improvement Plan By requiring the staff of the emergency department to reexamine its actions on that day, a dialogue is created that hopefully will create a strong motivation to seek out better and newer ways to handle patients that require sedation and monitoring. If the participation is not there, then the motivation will not be created and change will not occur. One way of developing an improvement plan would be to apply the theories of change developed by physicist and social scientist Kurt Lewin in the 1950s. His change management model, known as Unfreeze-Change-Refreeze, refers to a three stage process of transitioning through change. Lewin believed that to begin any successful change process, one must first understand why the change must take place, and this is where the motivation for change begins. He stated that one must be helped to re-examine many cherished assumptions about oneself and one’s relations to others. This is the stage known as â€Å"unfreezing†. (Thompson, n.d., p. 1) In the case of the emergency department, the entire team needs to be compelled to change the way sedation procedures are performed, as well as how patients are handled before and after the procedure. In addition to reviewing the procedural sedation protocol, the team needs to look at overall hospital care of those receiving any medications that cause respiratory depression. This should not be too difficult to promote since the procedure performed that fateful day resulted in harm and subsequent death of a patient. Not only was the patient and his family harmed, the entire organization was harmed and is liable for this incident. The hospital and its emergency department’s community reputation is going to suffer. Knowing that the staff that day is probably emotionally traumatized and possibly fearful of the consequences, the environment is ripe for change and the unfreezing stage can begin with a review of the sedation policy and why it was not followed. Each individual there and staff that were not there that day need to be made aware and can meet one on one with the department manager to voice their concerns and questions. Barriers hopefully will be identified as to why the sedation protocol was not followed that day. The hospital already provides an electronic educational module on conscious sedation procedures which would have a required date for staff to complete. This module should be reviewed for any inconsistencies  and updated and it should be made easily accessible on the computer portal. The actual written policy should also be easily accessible on the portal as well as in print form in a binder at the nurses station, should staff not have access to the computer. An analgesic protocol could be developed in which there would be a minimum time lapse between opioid doses (for instance 10 minutes versus 5) and the use of a hospital approved sedation scoring system should be in place. Patients in addition to requiring continuous pulse-oximetry monitoring should also be on continuous end tidal CO2 monitoring as well, long considered a more effective way of measuring effective ventilatory status. A new electronic training module on the use of end tidal CO2 monitoring would be mandatory for nursing staff to complete and equipment in the ED would be upgraded to provide for this type of monitoring. A representative could come and demonstrate the use of this type of monitoring and sign off employees for a mini-education module. Although many emergency departments have upgraded their documentation to all electronic, it might be helpful for staff nurses who are continuously monitoring patients at the bedside to use paper forms to document the pre procedure requirements including consents, time-outs, intra procedure medications and response to those meds and vital signs as well as post procedure Aldrete scores and recovery notes. This would be advantageous for simply the reason that not every bed has access to a computer. Health care providers certified in Advanced Cardiac Life Support (ACLS) must be in direct attendance with the patient throughout the entire course of the sedation and until the patient is fully recovered. Their primary responsibility is to monitor the vital signs including heart rate and rhythm, blood pressures, respiratory rate and oxygen saturation, as well as the patency of the patient’s airway. The RN managing the patient should never leave the patient unattended or engage in tasks that would compromise this continuous monitoring. The RN is responsible for taking the leading role in assuring that the care provided is safe. Proper airway equipment and drug reversal agents should be at the bedside and this must be documented. In order to unfreeze the staff and help them to change their behaviors, the ED could hold mock sedation procedures to practice their skills in managing a sedated patient. Annual skills days should be held with  review of the policy and equipment used. Staff would be signed off annually on this module. Certifications for BLS(basic life support), ACLS, PALS(pediatric advanced life support) and possibly TNCC (trauma nurse core curriculum), should be up to date and the hospital should offer these courses on campus to make it easier for their employees to maintain their certifications. Staff members whose scope of practice do not require them to practice ACLS or PALS should be reeducated on what normal vital signs are, how to set parameters on the cardiac monitors, how to take vital signs on the cardiac monitor and they need to review basic BLS skills by attending their own skills day. Teaching should include basics on what normal vital signs are for different age groups, and how medications can alter these vital signs. If the hospital has the funds to open a simulation lab, all nurses and allied health personal could practice simulated scenarios on mannequins and even videotape them. This would be a huge asset for the staff of all the patient care departments. Another part of the improvement plan would include classes for staff on communication and critical conversations. Learning how to communicate as a team and voice concerns about patient safety is a skill that requires practice, confidence and no fear of retribution or intimidation. Staff members who deal in stressful and hectic environments may at times be uncertain when they see behaviors that are unsafe and therefore may elect to say nothing when they believe the care of a patient may be compromised. In the case of the LPN who turned off the SPO2 alarm, I would wonder if perhaps there was a communication barrier between her and the RN and or the MD, or was it simply a knowledge deficit. An action plan needs to be in place for a saturated emergency department in which additional staff can be called in with a less than 30 minute wait time, or perhaps float other available qualified staff from other departments, such as the critical care unit or the telemetry floor. Because critical care nurses are accustomed to working in a 1:1 environment with their patients, it would have been ideal to float a CCU nurse to the department when Nurse J realized she could not take care of the rest of the department without leaving Mr. B unattended. Of course this may not have  been feasible since we do not know the census in the CCU. Chart reviews are also an invaluable tool for improvement. The manager will assign nurse in the ED to perform a monthly audit of all sedation charts with checklists of what was done correctly and what was not. These audits are important for providing data on how the ED needs to improve its performance and safety measures. This data will be provided not only at ED staff meetings but at quality improvement meetings involving the nursing director and hospital administration. If there is a problem convincing the hospital to provide safe staffing levels, the ED must provide strong data in order to show administration that there is a need to provide additional nursing. After the uncertainty of the unfreeze stage has occurred, change then begins to take place. Staff will start to believe and act in ways that support the new growth of the department. The transition will not happen rapidly as people take time to learn and embrace new ways of doing things and for each individual the rate of change is personal. In order to accept the new change and contribute to its success, staff will need to understand how the changes will benefit them and not every person will feel this way. Most healthcare workers probably feel that if healthcare delivery is made safer and better for their patients, then they will buy in to the need for changes and produce those changes. Unfortunately some of these people may feel harmed by change, and it is possible to notice some folks not participating in meetings, outside events, or educational updates. They may voice discontent with the whole process and complain that the changes are unnecessary. They may feel the status quo is being challenged and are threatened if they are unable to adapt to the changes. They may eventually leave the department or even the hospital environment as a whole. These are the people who may require the most encouragement and handholding to get them through the transition. Time and communication are of utmost importance and as staff gains understanding of the changes, they also need to feel connectedness to the organization throughout the transition period. (Thompson, n.d., p. 3) Lewin’s third stage of change, or Refreezing, takes place when the organization has identified the barriers to sustain the changes made, and when it has identified what makes the changes work. Employees feel  confident and comfortable using new communication techniques, they participated in learning the new procedures and feel supported by their peers and leadership. There is an established feedback system for employees to participate in regarding their education and training, in which they can voice what works and what doesn’t. Changes are now used all of the time and are incorporated into the normal day to day operations in the ED. If the changes are not used regularly and not anchored in to the culture of the ED, the refreezing state cannot occur and employees may get caught in a â€Å"transition state† where each person is not sure how things should be done and there is no consistency for policies and procedures being followed. For the refreezing states to be successful, the department should celebrate its success with the change. Employees will need to have a sense of closure and management needs to help them feel appreciated for enduring an uncertain and uncomfortable time. It is important to encourage staff to believe that the contributions they have made have made the changes a success. (Thompson, n.d., p. 4) Continuing to provide support and transparency keeps employees informed and motivated to preserve the new changes in place. Allowing staff to voice their opinions and participate in how changes are rolled out is part of this process. Overall, a team approach to care is of utmost importance in the ED and each individual should be encouraged and reminded regularly how important their contributions are to the whole. Reward systems to encourage pride and enthusiasm for work well done can be included at monthly staff meetings. One or two employees might receive a gift or a trophy for hard work, these recipients would be nominated by their peers who anonymously write a nice note about someone who did something nice for a patient or a staff member or just did a particularly great job that day. Team building activities can also include an organized activity outside of the ED where employees and their family members can socialize together and relax. Nursing leaders and managers should strive to build environments that are conducive to friendships, facilitating and promoting good communication and respectful communication between nurses, physicians and administrators. (Blosky & Spegman, 2015, p. 34) Trust is the cornerstone of good communication, which was sorely lacking in the ED that day. C. Use a failure mode and effects analysis to project the likelihood that the  process improvement plan you suggest would not fail. (Identify the members of the interdisciplinary team who will be included in the RCAS and the FMEA) FMEA is a step by step process used to identify all possible failures in a design , a manufacturing or assembly process or a product or a service. FMEA was started by the US military in the 1940s, and was further developed by the aerospace and automotive industries. (American Society for Quality [ASQ], n.d., p. 1) It has been adopted by the healthcare industry successfully as a tool to identify areas of healthcare processes tat may fail, in order to prevent harm or sentinel events before they occur. â€Å"Failure modes† are the ways, or modes in which something may fail. Failures are errors or hazards, which affect the customer and in healthcare the customer is usually the patient. These errors or hazards can be actual, or potential. Effects analysis is the study of consequences of those failures. Failures are prioritized in order of how severe the consequences are, their frequency of occurrence, and their ease of detection. The purpose of the FMEA is to eliminate or reduce the percentage of failures, starting with the highest priority areas. (ASQ, n.d., p. 1) In the scenario of Mr. B, unfortunately the FMEA cannot change the outcome, but it will be a proactive method of developing a new policy and procedure for how sedation cases are handled in the emergency room setting. The FMEA will be used to evaluate the new protocol for sedation procedures as well as staffing protocols related to monitoring 1:1 patients. This evaluation will occur before the actual implementation and will be used to assess its impact on the existing protocols.(IHI, 2015, p. 1) The process that needs to be evaluated and improved specifically to the case of Mr. B, would be the moderate sedation policy and its specifics to requirements of staff during the procedure and the recovery period. Some of the failure modes that may occur or have the potential to occur would be staff resistance to change, inexperienced nurses or practitioners with lack of education, inadequate ability to staff the ED appropriately during influx of patients, sick calls, or inadequate equipment or equipment failure. (Study Mode, 2014, p. 12) The key to a successful FMEA will be the involvement of a interdisciplinary  team, which would most likely consist of the some of the same members of the RCA. An emergency room physician, preferably the director, director of respiratory therapy, the hospital pharmacist, the ED nursing director, a risk manager, a head administrator who can lead the group in decision making, one or two ACLS certified staff nurses from the ED that perform sedation procedures, head of anesthesiology, and possibly even members from other departments where moderate sedation is performed. The team will need to meet regularly and be committed to providing continuing support during the course of implementation. C1: Interventions With the unfortunate scenario of Mr.B, it is now up the the interdisciplinary team to begin testing interventions that will or may be integrated in to the new plan for management of moderate sedation patients, with the goal of improving safety and eliminating adverse events. Once the established team has focused their aim, their next step would be to test a change or a few changes in the ED. This would be done with subsequent procedural sedation procedures which are commonplace in the ED. A small but major change to test would be the mandatory presence of an ACLS certified RN in 1:1 care of the patient from the beginning of the procedure and throughout it to discharge. The goal of this change is to prevent adverse events from respiratory depression in 100% of all patients receiving sedation in the following 6 month period. Performing this test several times will enable the team to see if the staff is actually complying with the new protocol and what barriers there are to prevent it from being successful. Staff will give feedback later as to what is working and what is not, and what they think needs to be done to make the changes work. An effective way to implement testing would be to utilize a PDSA cycle. The Plan-Do-Study-Act (PDSA) cycle is known as shorthand for testing a change by planning it, trying it, observing the results, and acting on what is learned. (Institute for Healthcare Improvement [IHI], 2015, p. 1) According to the Institute for Healthcare Improvement, the reasons to teats changes are as follows: To increase ones belief that the changes will result in improvement To decide which of several proposed changes will lead to the  desired improvement To evaluate how much improvement can be expected from the change To decide whether the proposed change will work in the actual environment To decide which combinations of changes will have the desired effects on the important measures of quality To evaluate costs, social impact, and side effects from a proposed change To minimize resistance upon implementation The Institute for Health Improvement lists these steps in the PDSA cycle to include: Step 1: Plan Plan the test or observation, including a plan to collect the data State the objective of the test: â€Å"Minimize or eliminate adverse events from respiratory depression while being monitored in the ED under conscious sedation† Make predictions about what will happen and why Develop a plan to test the change (Who, what, when where? What data needs to be collected?) Step 2: Do Try out the test on a small scale: maybe only perform the test in a 3 week period, on sedation procedures performed between the busiest times of the ED, for example between noon to 6pm. In a 6 bed rural ED, this might actually be the busiest time period. Carry out the test Document problems and observations, unexpected and expected Begin analysis of the data Step 3: Study Set aside time to analyze the data and study the results, for example: a biweekly or monthly meeting of the FMEA team. Complete the analysis of the data Summarize and reflect on what was learned Step 4: Act Refine the change, based on what was learned from the test. Determine what modifications should be made. Prepare a plan for next test, probably on a larger scale. For example, test all sedations over a month , for actual 24 hour periods in the ED. In addition to performing the PDSA cycles, the ED could appoint a volunteer or volunteers from the department to form a safety committee with a leader being the liaison who would have the authority to come up with quick solutions to certain problems that are encountered in the department on a daily basis. The liaison would take care of fixing broken equipment or replacing it, ordering new equipment and providing user training, communicating with staff about safety concerns and bringing these concerns to management and the FMEA team. The safety liaison would be trained in Human Factors Engineering, the science of why people make mistakes. The staff will need to be reassured that this person is their ally and not an informant or disciplinarian. (Institute for Healthcare Improvement [IHI], 2015, ∂ 1) This is a person they should feel comfortable reporting their concerns to. This person could take an active role in the PDSA testing and collect data as which could be added to the monthly chart audits of all the conscious sedation procedures performed since that fateful day with Mr. B. C2: Presteps: Discuss the pre-steps for preparing for the FMEA. Step one in preparing for the FMEA in regards to revising the sedation protocol involves selecting a specific process to evaluate. While there were many factors that contributed overall to the sentinel event that occurred , the FMEA should be focused on a sub process. Conducting an FMEA on a combination of the sedation protocol, the staffing ratio issues, the communication problems between staff members, knowledge deficits of staff and equipment issues would be an overwhelming task, so instead we will consider individual analysis of each variant. In this case, we are going to focus on creating a better defined policy on how to safely perform conscious sedation in the emergency room setting in order to prevent further sentinel events. We want to define in the policy what licensed and certified personnel is to be present and performing the procedure, and step by step spell out what is required of those team members from the time of informed consent to the time the patient is discharged from the ED. The policy needs to be easily accessible and there needs to be a standard way of making sure staff has read the policy and understands how to follow it. The goal is to make sure that the patient has 1:1 care at all times with qualified  personnel and leaves the ED in stable, improved condition. The second pre-step is to recruit the multidisciplinary team, including everyone who is involved at any point in the process. Be clear that not all people need to be included on the team throughout the entire process, but should be part of the discussions in which they are or did participate in the process. For example, In the case o f Mr. B, radiology was probably at the bedside performing pre and post reduction films, in which the RN clearly would not have remained at the bedside unless he or she was wearing a lead apron. Pharmacy may have become involved if they had to mix any post resuscitation drips for the patient after he returned to a sinus rhythm from ventricular fibrillation. The secretary was involved in calling a rapid response team, and members of that team may be able to provide valuable insight as well. The third pre-step is to have the team meet together to create a list of all of the steps in the process. Every step should be numbered and be as detailed as possible. Note that this may take numerous meetings to complete this portion, due to all of the variables and complexities. Using flowcharts helps team members to visualize the processes more clearly and create a more understandable outline of the steps. There needs to be a group consensus that the outlined steps of the FMEA correctly show the process. By creating a step by step flow sheet the team will be able to visualize the scenario in detail and begin the process of elimination of what does and does not work and move on to pre-step 4. The team will now begin to list all of the possible failure modes. Possible failure modes include absolutely anything that could go wrong, such as the following: Staff not trained in protocol Staff not knowing how to properly use equipment Monitor not connected to patient Equipment not plugged in Medications not reconciled Communication problems between peers Assessments not completed Ancillary staff not educated IV fluids not running Patient experienced respiratory arrest These are just of the few of the possible failure modes that could be listed. For each of these failure modes, the team must list a cause. For example, in the case of Mr. B, he was never connected to a cardiac monitor until he went unresponsive, so the team must try and explain the cause of this. Prestep #5 , for each failure mode, the team will need to assign a numeric value which is called the Risk Priority Number or RPN. The RPN is a measurementof three variables: the likelihood of the failure occurring, of it being detected, and its severity. This is a scoring method that assists the team in determining what areas need the most most focus on improvement. C3 Three Steps: Once again, assigning numeric values to three separate variables assists the team in determining the issues which should be prioritized in order of importance, or the need for improvement. The three topics are as follows:( IHI, 2015, p. 4) the likelihood of occurrence: In other words, how likely is it that this failure mode will happen† A score between 1 and 10, with 1 meaning â€Å"very unlikely to occur† and 10 being â€Å"very likely to occur†. In the case of Mr. B, had a FMEA already been in place prior to his visit to the ED, the likelihood of his demise would have been much more unlikely to occur. But the system had failed him and due to all of the multiple mistakes that did occur that day, the likelihood of what happened was higher up on the numeric scale. the likelihood of detection: If this failure mode does happen, how likely is it that it will be detected? † A score between 1 and 10, with 1 meaning â€Å"very likely to be detected† and 10 being â€Å"very unlikely to be detected.† On the day of Mr. B’s demise, there were multiple opportunities for the staff to detect that there was a potential problem, but they did not. No one noted the lack of staff, communication was poor, and proper equipment was not utilized. So, this question goes back to the Root Cause Analysis and in the FMEA the team will need to determine how the staff can detect these failures before harm occurs again to someone else. the severity: If the failure mode happens, what is the likelihood that the patient will be harmed? † A score between 1 and 10, with 1 meaning â€Å"very unlikely that harm will occur† and 10 being â€Å"very likely that severe harm will occur†. According to the IHI, a score of 10 often means death. In Mr. B’s case, the consequence that resulted from the  failures in the ED that day was his untimely death. So the severity rating for that particular day would be a 10. D. Discuss how the professional nurse may function as a leader in promoting quality care and influencing quality improvement activities: The professional nurse plays a critical role in hospital quality improvement, since nurses are the primary caregivers in the system of healthcare. They are pivotal in improving the processes in which care is provided. According to Cynthia Barnard, MBA, the role of the professional nurse in quality improvement is two-fold: to carry out interdisciplinary processes to meet organizational QI goals, as well as measuring, improving and controlling nursing sensitive indicators affecting patient outcomes specific to nursing practices. She states that all levels of nurses, from the direct care at the bedside, to the chief nursing officer (CNO), play a part in promoting QI within the healthcare provider organization. (HCpro, 2010, p. 1) Ms. Barnard lists the following levels of nursing and their professional responsibilities: The CNO: The CNO sets the tone for the nursing departments participation in QI. As an administrator, the CNO is responsible for integrating nursing practices in to the organizational goals for excellence in patient outcomes by communicating the strategic goals to all the levels of staff. The nurse manager (NM) or nursing director: The NM or director is responsible for communicating and operationalizing the organization’s QI goals and processes to the bedside nurse. The NM identifies specific nursing sensitive indicators that need improvement according to the organization’s specific patient population and coordinates QI processes to improve these at the unit level. The direct care nurse: The bedside nurse is the key to quality patient outcomes, carrying out the protocols and standards of care shown by evidence to improve patient care. Important to this provision of quality care is the fact that professional nursing leaders are the key factor in setting the tone and providing an environment in which all health care staff feel empowered to uphold these expectations. If nursing leadership and administration feel that they have less than adequate engagement of staff, it may be simply because the staff may not always understand the rationale and momentum  behind particular quality improvement initiatives. For nurses to be involved in delivering high quality care, it is imperative that leadership allows the participation of staff nurses into the design and implementation of processes by continuously educating and informing them, instead of simply telling nurses what they are supposed to do. A hospital culture that encourages quality as everyone’s responsibility is most likely to achieve sustained and noticeable improvement. Because nursing practice occurs in the context of a larger team, the impact of other departments and practitioners must be included in leadership’s efforts to improve quality. (Draper, Felland, Liebhaber, & Melichar, 2008, p. 4) By having every staff member engaged, including the other members of clinical staff, ie; physicans, respiratory therapy, even housekeeping and dietary management, accountability for patient safety and quality becomes a group effort and does not rest mainly on the shoulders of the nursing population. References American Society for Quality (n.d.). Failure Mode Effects Analysis (FMEA). Retrieved July 3, 2015, from http://asq.org/learn-about-quality/process-analysis-tools/overview/fmea.html Blosky, M. A., & Spegman, A. (2015). Communication and a healthy work environment. Nursing Management, 46(6), 32-38. Cherry, B., & Jacob, S. R. (2011). Contemporary nursing; issues, trends and management. Available from https://online.vitalsource.com/#/books/978-0-323-06953-3/pages/52165015 Draper, D. A., Felland, L. E., Liebhaber, A., & Melichar, L. (2008). The rrole of nurses in hospital quality improvement. Retrieved July 3, 2015, from http://www.hschange.org/CONTENT/972 Frain, J., Murphy, D., Dash, G., & Kassai, M. (n.d.). . Retrieved, from Galley, M. (n.d.). Basic elements of a comprehensive root cause investigation; three steps and three tools that organize and improve your problem solving capability. Retrieved June 29, 2015, from rootcauseanalysis.info HCpro (2010). Ask the expert: Understanding nur sing roles in quality improvement. Retrieved July 6, 2015, from www.hcpro.com/NRS-248978-868/Ask-the-expert-Understanding-nursing-roles-in-quality-improvment.html Institute for Healthcare Improvement (2015). Failure modes and effects analysis. Retrieved July 3, 2015, from

Porter’s Five Forces

Porter’s 5 forces summary According to Porter, in order to achieve competitive advantage over its competitors, analysis of current industry structure is vital because the structure of an industry determines the nature of the competition and the form that a sustainable competitive advantage takes and the industry structure is determined by the five competitive forces; the treat of substitute, the treat of entry, bargaining power of buyer, and bargaining power of supplier and the intensive of rivalry. Porter work simplified to identify five forces and then, to select one of the generic strategies.Last step of his framework is using the value chain from identifying and enhancing the business activities. His concept is based on the idea that forces facing the industry play a key role in determining success and profitability of an organisation. The analysis of five forces tells how management should respond to and try to influence those forces in a favourable way. Threat of entrant s: according to Porter new entry into the industry certainly reduces the existing firm’s profitability. How high the entry barrier of the industry affects the degree of new entry:Simply, internet banking dramatically lowers the entry barrier of bank industry. It is because entry barriers such as ‘economics of scale’, ‘brand identity’ and ‘access to distribution’ do not work any longer. Physical size can only mean high operating cost as well as in efficient and limited degrees of flexibility. The banking market is likely to see the emergence of new small banks that use internet to compete on equal ground with the financial giants. Power of buyer: buyer power affects the prices that firms can charge.Porter theorised that the more products that become standardised or undifferentiated, and hence more power is yielded to buyers. The products of banking market are getting similar therefore it increases the bargaining power of buyers. Also, buy ers have full information on demand and cost with internet, it implies that they can play the game more rationally with significant bargaining power. As more new comers are expected to enter the industry, banking customer are facing more alternatives. This is evidenced by the fact that internet banking services are now free of charge. Porter’s Five Forces Porter’s 5 forces summary According to Porter, in order to achieve competitive advantage over its competitors, analysis of current industry structure is vital because the structure of an industry determines the nature of the competition and the form that a sustainable competitive advantage takes and the industry structure is determined by the five competitive forces; the treat of substitute, the treat of entry, bargaining power of buyer, and bargaining power of supplier and the intensive of rivalry. Porter work simplified to identify five forces and then, to select one of the generic strategies.Last step of his framework is using the value chain from identifying and enhancing the business activities. His concept is based on the idea that forces facing the industry play a key role in determining success and profitability of an organisation. The analysis of five forces tells how management should respond to and try to influence those forces in a favourable way. Threat of entrant s: according to Porter new entry into the industry certainly reduces the existing firm’s profitability. How high the entry barrier of the industry affects the degree of new entry:Simply, internet banking dramatically lowers the entry barrier of bank industry. It is because entry barriers such as ‘economics of scale’, ‘brand identity’ and ‘access to distribution’ do not work any longer. Physical size can only mean high operating cost as well as in efficient and limited degrees of flexibility. The banking market is likely to see the emergence of new small banks that use internet to compete on equal ground with the financial giants. Power of buyer: buyer power affects the prices that firms can charge.Porter theorised that the more products that become standardised or undifferentiated, and hence more power is yielded to buyers. The products of banking market are getting similar therefore it increases the bargaining power of buyers. Also, buy ers have full information on demand and cost with internet, it implies that they can play the game more rationally with significant bargaining power. As more new comers are expected to enter the industry, banking customer are facing more alternatives. This is evidenced by the fact that internet banking services are now free of charge. Porter’s Five Forces Porter’s 5 forces summary According to Porter, in order to achieve competitive advantage over its competitors, analysis of current industry structure is vital because the structure of an industry determines the nature of the competition and the form that a sustainable competitive advantage takes and the industry structure is determined by the five competitive forces; the treat of substitute, the treat of entry, bargaining power of buyer, and bargaining power of supplier and the intensive of rivalry. Porter work simplified to identify five forces and then, to select one of the generic strategies.Last step of his framework is using the value chain from identifying and enhancing the business activities. His concept is based on the idea that forces facing the industry play a key role in determining success and profitability of an organisation. The analysis of five forces tells how management should respond to and try to influence those forces in a favourable way. Threat of entrant s: according to Porter new entry into the industry certainly reduces the existing firm’s profitability. How high the entry barrier of the industry affects the degree of new entry:Simply, internet banking dramatically lowers the entry barrier of bank industry. It is because entry barriers such as ‘economics of scale’, ‘brand identity’ and ‘access to distribution’ do not work any longer. Physical size can only mean high operating cost as well as in efficient and limited degrees of flexibility. The banking market is likely to see the emergence of new small banks that use internet to compete on equal ground with the financial giants. Power of buyer: buyer power affects the prices that firms can charge.Porter theorised that the more products that become standardised or undifferentiated, and hence more power is yielded to buyers. The products of banking market are getting similar therefore it increases the bargaining power of buyers. Also, buy ers have full information on demand and cost with internet, it implies that they can play the game more rationally with significant bargaining power. As more new comers are expected to enter the industry, banking customer are facing more alternatives. This is evidenced by the fact that internet banking services are now free of charge.