Root Cause Analysis
A faith-based, nonprofit hospital in Florida had a periodic problem with its Food Services department. One or two patients each week did not receive an evening meal from Food Services. In some cases, the patient complained to the attending nurse, who then found a frozen dinner, warmed it, and delivered it to the patient. In other cases, the patient said nothing at the time but later complained to family members or noted the problem on the patient satisfaction survey. When nurses occasionally complained to Food Services staff about the missing dinners, the only response was that “the patient was not on the list.” The nurses decided that the easiest solution was to have on hand a few frozen dinners for patients who were not on the list and complained.
One enterprising nurse decided to go directly to the director of Food Services to determine why a particular patient was not on the list and had not received dinner. She found that while most patients either already registered the day before or had been admitted earlier in the day (between 7 am and 2 pm), information on the few patients admitted later might not have been transmitted to Food Services. The director had asked that the list of patients, patient room numbers, and special dietary needs be transmitted to him by 3:30 pm each day. If patient registration information had not yet been completed at that time, the patient’s name would not be on the list, and the patient would not receive a dinner that night (Fottler, Ford, & Healton, Year?). For your paper, please include:
- What is the root cause of this problem? How can the root cause be addressed so that it is eliminated in the future?
- If the hospital had a similar system problem in another area, how would you suggest it manage that problem? Base your response on a situation in which x-ray or lab test results sometimes arrive too late for the attending physician to consider in the treatment of patients.
Your paper should be a minimum of two to three pages in length, excluding the title and reference pages, and formatted according to APA guidelines