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Week 7 Assignment 3: Design Failure Mode and Effect Analysis Report
Assignment Background: This assignment will require you to research the existing types of physical plants for secured units. After conducting your research, you will create a Design Failure Mode and Effect Analysis (DFMEA) Report that addresses specific information, as outlined below, which can be delivered in any format. You will also have to create at least one visual aid, which must be included within your report. It is recommended that you use appropriate headers for each section of your report to ensure all aspects of the assignment are clearly identified. Consider reviewing some of the resources provided at the bottom of the page or visit the LTC Administrator’s Toolkit Week 7 Resources to support you with your research.  
Assignment Requirements:

Create a DFMEA Report:

Include all Content Aspects provided below in the assignment prompt.
Freestyle formatting allowed. You determine how you want the report to look.
Create one visual aid to support your findings.
Minimum of five pages, excluding the cover page and reference page.
The report should not exceed ten pages, excluding the cover page, reference page, and visual aid.

References and Correlating In-Text Citations:

Provide at least five scholarly sources, professional publications, and/or articles.
Two of the five resources must be from your own research. The other resources may come from the weekly content or toolkit.
All references must be from the last five years.
Every reference must have a correlating in-text citation(s).

APA 7th Edition:

Follow APA 7th edition formatting and style.
Include an APA 7th edition cover page.
Include an APA 7th edition reference page.

Due Date: Tuesday of Week 7 by 11:59 pm EST.

Your DFMEA Report Must Include the Following Information for Each Content Aspect:
Aspect A of the Report: Introduction, State Residence, and Physical Plant Summaries

Identify the two types of secured units that you will research.

Examples: Alzheimer’s Adult Day Center, Dementia Unit in a Skilled Nursing Facility, Memory Care Assisted Living Facility, Geriatric Psychiatric SNF, Memory Care Unit that is part of a Continuing Care Retirement Community (CCRC), Home-Based LTC Setting that is Locked, or any type of secured/locked facility that is of interest to you.

Select a state residence to apply to your selected LTC settings.

Your selection should be based on your current state’s residence, or prior state’s residence such as Maryland, Georgia, or any of the applicable 50 states. You will use your identified state residence to address the applicable aspects of your report.

Describe the following elements for each of the physical plants’ descriptions: 

Number of licensed beds or square footage of each LTC facility/setting.

Note: If you research did not provide a specific number of beds or square footage, then offer a hypothetical number of licensed beds or square feet to apply in your report.

Number of LTC residents served, or potential average daily census, of each LTC facility/setting.

Note: If you research did not provide such information, then offer hypothetical information to apply in your report.

Type of locking devices, secured devices, or means of egress used in each LTC facility/setting.

Note: If you research did not offer this information, then decide on locking devices or means of egress to apply in your report.

Other key physical plant description items for each LTC facility/setting.

Note: Offer information on the key characteristics, providing a sufficient description of the settings.
Examples: Stand alone facility, unit part of a facility/senior living community, number of floors, outdoor space, number of exits, age of facility/setting, or similar items to ensure a detailed description is provided. 

Aspect B of the Report: Specific Design Failure Mode and Effects Analysis

Select one of the settings that you researched in Aspect A: Conduct a DFMEA drill, include at least two failure points for one of your selected LTC facility/setting from Aspect A. Determine why the expected or intended function did not occur, include the following four areas in your analysis:

Failure Mode and Failure Effect: Include (a.) at least two failure modes; (b.) the details for each point; (c.) the way the failure could be observed; (d.) immediate consequences of each failure on the operation, function, and/or functionality; and (e.) information on the potential impact of the residents, staff, and LTC setting.

Failure Cause: Identify the underlying cause of each failure and explain why each failure may have occurred. Include at least two of the following items in your analysis: design, system, process, quality, or parts.

Severity Rankings: Identify the severity ranking of each failure and include one of the following areas in your analysis: worst case scenario, degree of injury, degree of damage, property damage, stakeholders’ harm, or facility/setting harm.

Facility-Level Responses & Assigned Responsibility: Include (a.) one design action; (b.) one design control method; and (c.) one recommendation to reduce the chance of failure modes in the future. Include information on the (d.) team or department that will be responsible for completing the action, control method, and recommendation, and share why they were selected.

Aspect C of the Report: Visual Aid of Your Findings

Create at least one visual aid that is based Aspect B of the Report.

The visual aid can be included in the report as an appendix, table, or figure, or may be presented in a separate document as a supplement.

Examples: DFMEA Template, DFMEA Steps, DFMEA Map, Specific Failure Mode Tables, or any visual aid that you would like to create to support your findings and information.

Aspect D of the Report: Your Assessment on the Findings for Your Selected LTC Setting

Provide an assessment of your findings that includes:

Conclusions on the (a.) operational effectiveness; (b.) influence on potential evacuation plans/needs; and (c.) connections between the failures to quality of care outcomes for the residents of the secured setting based on your DFMEA research conducted.
Licensure compliance for your selected state and any applicable federal requirements. 

Must provide at least two requirements, laws, or standards. 

Examples: Specific federal regulations, state-specific regulations, city ordinances, or similar regulatory considerations for state licensure compliance.

If your selected state residence does not have any specific requirements for locked or secured units, then include how you validated this information and the type of source that was used to validate this information.

Provide the greatest lesson learned from conducting this analysis and how you could apply it to your future career.

Resources to Assist You with this Assignment: 
This information offers details on DFMEA, FMEA, Fire Safety Code, Life Safety Code, Federal K-Tags, E-Tags, CMS Survey Information, and much more! Consider reviewing some of the videos, reading a few of the PDFs, and exploring some of the websites as these resources may assist you with your Week 7 Assignment.
Website Links: 

Website link on Design failure mode and effect analysis
Quality One Website Article on DFMEA:  https://quality-one.com/dfmea/
iSixSigma Website on DFMEA: https://www.whatissixsigma.net/dfmea/
Revisions to the Life Safety Code Health facilities compliance experts review changes included in recent editions of NFPA 101: https://www.hfmmagazine.com/articles/4108-revisions-to-the-life-safety-code
Institute for Healthcare Improvement FMEA Tool Website Link: http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx
CMS Life Safety Code & Healthcare Facilities Code Requirements: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/LSC

Publications, State Operations Manuals, and Articles: 

NFPA 1010 Life Safety Code 2018 PDF
Medicare SOM Appendix (CMS Medicare State Operations Manual (SOM) Appendix: Click on any appendix letter in this PDF to access specific SOM information. You can also access this information by searching on the CMS website.)
CMS QAPI Guide for Performing Failure Mode and Effects Analysis with Performance Improvement Projects PDF
CMS State Operations Manual Appendix I Survey Procedures for Life Safety Code Surveys PDF
Joint Commission Information on Locked Units PDF
Complying with Door Locking Requirements Life Safety Code Publication from 2018 PDF

Videos:

Common Life Safety Code Deficiencies and Strategies for Compliance: https://www.youtube.com/watch?v=CYTdOHzi4jQ
Fire & Life Safety Compliance in Health Care Facilities Video: https://youtu.be/Clljdpst4cU
How to create a DFMEA Design Failure Modes and Effects Analysis: https://youtu.be/gRTn2QDrCbg
An Overview of the Failure Modes and Effects Analysis (FMEA) Tool from the Institute for Healthcare Improvement (IHI): https://youtu.be/PIEzR5uhqnw
Emergency Preparedness & Life Safety Code Update: https://youtu.be/ZoiMLnJzNL4
NFPA 101 Life Safety Code 2018 Edition: https://youtu.be/qsTIWTJTatU