At my current organization, we use the A3 method for quality improvement initiatives. We have a Lean Six Sigma Blackbelt at our organization and all of the directors and managers are at least certified Green Belts in the Lean Six Sigma training. The A3 form/format is utilized for patient-related harms reported across the organization. This primarily includes Hospital Acquired Pressure Injuries (HAPI’s), Catheter-Associated Urinary Tract Infections (CAUTI’s), and Venous Thromboembolisms (VTE’s). Although we follow a similar format previously described in the steps above for the A3, our organization asks specific questions for each step of the A3 process. This is very helpful when ensuring that clinicians do a deep dive into the reasons for the harm, as well as identifying opportunities to improve the quality of patient care and prevent further harm.
The most recent incident that we need to complete an A3 was for a harm on the Palliative Care unit. A bedridden patient developed a HAPI, a stage 2 pressure injury on their right heel (Step 0). Upon review of the chart/patient flow, staff processes/procedures (Steps 1-8), the patient was not being turned every two hours per organizational policy. It was further determined that the patient was boarded in the ED for 36 hours, prior to being admitted to the Palliative care unit. Consequently, the ED had to take responsibility for the harm, considering that the patient had only been on the Palliative care unit for less than 24 hours. Ultimately, the organization needs to ensure that all departments are following our policies related to turning identified patients, every 2 hours (Step 9). Ongoing, the Performance Excellence Committee reviews data/patient records, to ensure that there are no additional harms (Step 10). Once the A3 document is completed, it is reviewed with the harms team, and approval is sought for any changes in practice, protocol, policy, etc.
References
Montana State University (n. d.). Steps of the A3. Retrieved from https://www.montana.edu/dsobek/a3/steps.html
Order this paper