NUR 531 Module 7 Project Two Example

Project Two: A Proactive Systems Assessment of Water Safety When Rooms Close and Construction Begins

[Student Name]

Southern New Hampshire University

NUR 531: Interprofessional Leadership in Healthcare

Project Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Project Two: A Proactive Systems Assessment of Water Safety When Rooms Close and Construction Begins

A root cause analysis explains why something went wrong once. A proactive assessment asks where the same system could fail next. Since the Legionnaires' case on the oncology unit, the Wren Valley water management team has fixed the causes it found. It now faces two more renovation phases that will close rooms, change valves and bring in outside contractors, the very conditions that preceded the case. This project assesses that process with Healthcare Failure Mode and Effect Analysis (HFMEA), a prospective method that the Veterans Affairs patient safety center adapted from engineering for use in hospitals (DeRosier et al., 2002). The assessment finds that the process is most likely to fail at the handoffs between departments, when a room's status changes and no one downstream is told, and it proposes automatic triggers and verification steps that close those gaps before the next phase begins.

Scope and Team

The process assessed runs from the decision to take a patient room out of service, for any reason and any length of time, to the moment it is safely returned to use, together with any construction or valve work that affects the water serving that room. The team included the facilities director and a plumbing supervisor, the infection preventionist, the environmental services manager, the construction project manager, a staff nurse from 4 East, a facilitator from patient safety and, representing the oncology unit's leadership, me. Alongside people who run the process every day, the team deliberately included someone new to it, so that familiar steps would be questioned; the construction project manager, who had never worked on water safety, filled that role.

The Process

The team mapped the process in five steps: (1) a room is closed and its closure is communicated; (2) flushing of the room's outlets is scheduled; (3) flushing and checks are carried out while the room is closed; (4) construction or valve changes affecting the room are reviewed; and (5) before the room reopens, its water is flushed, checked and released for patient use. Each step was then broken into the tasks and handoffs that make it up, and the team asked of each task how it could fail.

Hazard Analysis

HFMEA scores each failure mode for severity, from minor (1) to catastrophic (4), and probability, from remote (1) to frequent (4); the product is a hazard score from 1 to 16, and modes scoring 8 or more go through a decision tree that asks whether the step is a single point of weakness, whether some safeguard already handles it and whether anyone would plainly notice the failure in time (DeRosier et al., 2002). Table 1 shows the eight failure modes the team scored.

Table 1

HFMEA Hazard Scoring for Water Safety When Rooms Close

Note. Composite scoring by the assessment team. Severity: 1 minor to 4 catastrophic. Probability: 1 remote to 4 frequent.

Severity was rated catastrophic for most modes because exposure of immunosuppressed patients to Legionella can be fatal; among definite healthcare-associated cases in national surveillance, one in four patients died (Soda et al., 2017). Probability ratings drew on the root cause analysis and on the team's knowledge of how often each step had been missed. The three highest scores, 12 each, all sit at a handoff: a unit closing a room without telling facilities, a closure that never becomes a work order, and a contractor changing a valve without the water team knowing. The only mode that did not proceed, filter lapses, scored low because filter changes are already tracked by date on each filter housing and checked weekly by environmental services.

Actions

For each mode that proceeded, the decision tree found a single point of weakness with no effective existing control. Table 2 lists the actions, chosen to eliminate or control each hazard rather than accept it.

Table 2

Actions for Failure Modes That Proceeded Through the Decision Tree

The actions follow the water management approach set out in CDC's toolkit, which asks programs to identify where hazardous conditions could occur, set control measures and limits for them, monitor, and take corrective action when limits are not met (Centers for Disease Control and Prevention [CDC], 2021). They also answer the federal expectation that hospitals assess risk and manage their water systems actively rather than on paper (Centers for Medicare & Medicaid Services [CMS], 2018).

Tracking Plan

The water management team will review a one-page dashboard monthly. Table 3 defines its measures.

Table 3

Monthly Tracking Plan for the Water Management Program

Note. Composite targets set by the team.

Most of the measures are process measures, and that is deliberate. Healthcare-associated cases are rare enough that months without one prove little. The process measures show whether the controls are working long before a patient could be harmed. Any measure below target for two consecutive months will trigger a focused review, and the whole HFMEA will be repeated before each renovation phase begins.

Leadership Across Departments

Almost every action in this assessment belongs to a department outside nursing: informatics, bed management, facilities and construction. Nursing's contribution was the patient's perspective, which set the severity scores, and the unit's knowledge of how rooms actually close, often informally and at short notice. The staff nurse on the team pointed out that rooms are sometimes closed by the charge nurse for a single shift because of a broken bed, which no one else had considered. That observation widened the scope of the first failure mode and made the automatic notice necessary.

Conclusion

The assessment found that water safety at Wren Valley is most likely to fail where a room's status changes and the next department is not told. By replacing notification and memory with automatic triggers, forcing steps and verification before reopening, the proposed actions address the highest hazard scores before the next renovation phase. A monthly dashboard led by process measures will show whether the controls hold. The final project will turn these actions into an updated water management policy.

References

Centers for Disease Control and Prevention. (2021). Developing a water management program to reduce Legionella growth and spread in buildings: A practical guide to implementing industry standards (Version 1.1). https://stacks.cdc.gov/view/cdc/114167

Centers for Medicare & Medicaid Services. (2018). Requirement to reduce Legionella risk in healthcare facility water systems to prevent cases and outbreaks of Legionnaires' disease (LD) (QSO-17-30, revised). https://www.cms.gov/medicare/provider-enrollment-and-certification/surveycertificationgeninfo/downloads/qso17-30-hospitalcah-nh-revised-.pdf

DeRosier, J., Stalhandske, E., Bagian, J. P., & Nudell, T. (2002). Using health care failure mode and effect analysis: The VA National Center for Patient Safety's prospective risk analysis system. The Joint Commission Journal on Quality Improvement, 28(5), 248-267. https://doi.org/10.1016/S1070-3241(02)28025-6

Soda, E. A., Barskey, A. E., Shah, P. P., Schrag, S., Whitney, C. G., Arduino, M. J., Reddy, S. C., Kunz, J. M., Hunter, C. M., Raphael, B. H., & Cooley, L. A. (2017). Vital signs: Health care-associated Legionnaires' disease surveillance data from 20 states and a large metropolitan area: United States, 2015. Morbidity and Mortality Weekly Report, 66(22), 584-589. https://doi.org/10.15585/mmwr.mm6622e1