BHA-FPX4004 Assessment 3 Instructions Assignment

BHA-FPX4004 Assessment 3 Instructions Assignment

Assessment 3 Instructions: Collaborate on Quality: Issue Analysis and Leadership Action Plan

Prepare an issue analysis of an incident that occurred in a health care organization and create a leadership action plan (8-10 pages) that will help to address the specific incident but will also help to drive safety and quality improvements throughout the organization.

In this third assessment in the course, you will assume the role of a newly promoted quality manager at your local hospital. This role requires you to address deficiencies by improving organizational culture, providing leadership oversight, and cultivating staff relationships within the organization. While you have many priorities in this new role, one of your first is to analyze a recent incident that occurred within the organization and to create a leadership action plan with recommended strategies and tactics to address not just the specific incident, but to drive safety and quality improvement throughout the organization. BHA-FPX4004 Assessment 3 Instructions Assignment

This assessment differs from the first assessment in that with this assessment, as the quality manager, your focus is broader. Rather than focusing only on identifying specific actions the organization can take to remedy a

particular incident that occurred, you are concentrating on what steps you will take as the quality manager to influence the organization’s leadership to cultivate a fair and just culture. You will determine what departments, what leaders, and what personnel you will collaborate with to improve quality for the whole organization. In this type of culture, safety is at the forefront of everyone’s job and all associates welcome the opportunity to highlight issues— without fear of reprisal—so that they can be addressed at a systemic level throughout the organization.

You may find it useful to review the short document CQI Importance and Features [PDF] as you gather your thoughts about the key elements you want to include in your assessment, Issue Analysis and Leadership Action Plan.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

Competency 4: Apply leadership strategies to quality improvement in a health care organization.

Apply the IHI Triple Aim to develop a health care leadership strategy that focuses on optimizing health care system performance.

Propose evidence-based leadership strategies that will help to establish a safety and quality culture. Propose evidence-based leadership and collaboration strategies to enlist the aid of key organizational leaders in establishing a safety and quality culture.

Determine opportunities to enlist the governing board’s aid in fostering a fair and just culture. Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals.

Write a clear, organized, persuasive, and generally error-free issue analysis and leadership action plan that promotes a culture of safety and quality and is reflective of professional communication in the health care field.

Provide citations and title and reference pages that conform to APA style and format.

 

Preparation

To help prepare for successfully completing this assessment:

Select one of the three incidents from the Vila Health: Patient Safety simulation you completed in Assessment 1. These are common incidents you are likely to encounter in the health care field. These included a patient identification error, a medication error, and a HIPAA/privacy violation. You may select one of the incidents you worked with in the previous assessments or select another one. Pick one that holds the most interest for you.

Consider these analysis questions once you have selected the incident on which you will focus:

What information do you possess about the issue? (Note: You may not be able to answer all of these questions; just include the information you know.) Consider:

Who was involved?

During what process (clinical, communication, operational) did the issue occur? When did the issue occur? During a particular shift? On a particular day? During peak hours? Under certain clinical circumstances?

Where did the issue occur?

What additional data about the incident would you like to collect and analyze?

Which best practices may not have been adhered to that may have contributed to the issue? (Note: This information will prove useful to you as you complete your analysis and leadership action plan.)

Instructions

Write an analysis and leadership action plan for the issue you selected that will enable you to address the issue on an organization-wide basis. Please make sure to include all of the following headings and answer all of the questions underneath each heading.

Issue Summary

How would you summarize the key elements of the incident that occurred? What is your goal in addressing the issue?

Which two to three key items will be your focus? For example, you may elect to focus on nursing staffing levels if being short staffed in nursing is contributing to compromises to patient safety.

IHI Triple Aim

What is the IHI Triple AIM?

How does the IHI Triple Aim apply to this specific incident?

What IHI Triple Aim elements will you incorporate into your organizational improvement strategy?

Culture

What is culture?

Why is culture a critical organizational priority for safety and quality?

Based on the knowledge you have about the selected issue, what do you know about the existing organizational culture?

What are some of the evidence-based strategies you are considering you could employ to cultivate a culture of safety?

Collaboration

Which key departments need to be directly involved with the corrective action process?

What is your rationale for selecting these departments? For example, you may want to involve nursing because many of errors involve nurses and obtaining their buy-in is critical to achieving the organizational priority.

Which specific senior leader, front line staff member, and clinical expert will you include in your action plan and hold accountable for implementation?

What are the implications of not engaging with all departments toward making safety and quality top of mind?

LeaderHshoiwp might you involve other departments in addressing the specific issue and the cultural issue?

Which specific leaders within the organization could assist you in addressing this issue and in making patient safety and quality top of mind throughout the organization? Examples for you to consider include the chief nursing officer, the chief medical officer, the patient safety officer, et cetera. BHA-FPX4004 Assessment 3 Instructions Assignment

What role do you expect these leaders to play in addressing the specific issue and the issue of culture? What best practices would you employ to enlist their aid in the improvement effort?

What role does the organization’s governing board have in terms of quality and safety in the organization? How could you enlist the governing board’s aid in your improvement initiative?

What additional information could you provide them to increase their involvement in the organization’s safety and quality improvement efforts?

Leadership Action Plan

What are three evidence-based actions you recommend that would help to solve the incident that arose? What are three evidence-based best practices you recommend to address the issue on an organizational level?

Conclusion

How will you summarize your analysis of the incident and your leadership action plan?

Remember that health care is an evidence-based field. You will need to cite a minimum of two credible references to support your analysis and action planning process.

In addition, in the health care field, your analysis and action plan would not typically be written in APA format. Do ensure that it is clear, persuasive, concise, organized, and without errors in grammar, punctuation, and spelling. Do provide citations and title and reference pages in APA format. Other leaders in your organization are going to want to know what sources you relied on to prepare your analysis and action plan.

Additional Requirements

Length: Your incident analysis and leadership action plan will be 8–10 double-spaced pages, not including title and reference pages.

Font: Times New Roman, 12-point.

APA Format: Your citations and title and reference pages need to be in APA format. The body of your analysis does not need to be written in APA format. It does need to be well written, include the headings specified in the instructions, and address the questions listed under each heading.

Scoring Guide: Please review this assessment’s scoring guide to ensure you understand how your faculty member will evaluate your work.

SCORING GUIDE

Use the scoring guide to understand how your assessment will be evaluated.

Importance and Features of Continuous Quality Improvement (CQI)

Depending on the organization, continuous quality improvement (CQI) programs differ in size and scope. Likewise, they may be called a variety of names, such as quality and performance improvement, quality management, regulatory compliance, and quality improvement (Sollecito & Johnson, 2013). Despite the progress in CQI, health care quality improvement requires greater continued efforts due to the health care environment’s vibrant and complex nature.

CQI is a “structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations” (Sollecito & Johnson, 2013, p. 4). A common set of features characterizes CQI, which includes the following (Sollecito & Johnson, 2013, pp. 4–5):

• A link to key elements of the organization’s strategic
• A quality council made up of the institution’s top
• Training programs for
• Mechanisms for selecting improvement
• Formation of process improvement
• Staff support for process analysis and
• Personnel policies that motivate and support staff participation in process
• Application of the most current and rigorous techniques of the scientific method and statistical process

For CQI to flourish within an organization, it needs to be rooted in the organization’s culture. Culture is the combination of shared attitudes, values, competencies, goals and behaviors that define the organization’s practices (Silva, Barbosa, Padilha, & Malik, 2016). All stakeholders within the organization are responsible for health care quality and safety.

Leaders who wish to create a safety culture must first assess their organization’s readiness to implement the necessary safety practices. In addition, the Agency for Healthcare Research and Quality (AHRQ) has created culture assessment tools that allow organizations to identify benchmarks to establish a culture of safety in comparison to similar hospitals or hospital units.

The fair and just culture concept encourages leaders to ask what happened instead of who made the error (Pelletier & Beaudin, 2018). Additionally, a fair and just culture aids in making the system safer. Stakeholders understand errors are inevitable and that all errors need to be reported, even when events may not cause patient harm (Pelletier & Beaudin, 2018).

Pelletier and Beaudin emphasize how critical it is for leaders to assume responsibility for driving improved patient safety practices throughout the organization (2018). To demonstrate this, leaders need to incorporate health care safety practices as a part of the organization’s strategic direction and to develop goals to guarantee adoption and measurement of safe practices.

The governing body or board of directors is responsible for endorsing and upholding quality of care and preserving safety. Quality oversight is recognized more clearly as a core fiduciary duty relating not only to financial health and reputation but to safety and quality of care (Pelletier & Beaudin, 2018).

References

Pelletier, L. R., & Beaudin, C. L. (2018) HQ solutions: Resource for the healthcare quality professional (4th ed.). Philadelphia, PA: Wolters Kluwer.

Silva, Natasha Dejigov Monteiro da, Barbosa, A. P., Padilha, K. G., & Malik, A. M. (2016).

Patient safety in organizational culture as perceived by leaderships of hospital institutions with different types of administration. Revista Da Escola De Enfermagem Da U S P, 50(3), 490-497.

Sollecito, W. A., & Johnson, J. K. (2013). Mclaughlin and Kaluzny’s continuous quality improvement in health care (4th ed.). Burlington, MA: Jones & Bartlett Learning.

BHA 4004 CU Patient Safety & Quality Improvement in Healthcare Safety Issues Essay

Write a 5-7 page recommendation to senior leadership about steps the organization needs to take to resolve a patient safety issue that occurred. Include an explanation of why it is important to address the issue and the role the patient safety officer will play in helping to resolve the issue.

Alarming numbers of unnecessary patient deaths occur in U.S. hospitals and around the world. “Quality and patient safety in health care have been on the forefront of the public’s mind since the publication of the Institute of Medicine’s (IOM) seminal report, ‘To Err Is Human,’ in 1999” (Johnson, Haskell, & Barach, 2016, pg. xv). The literature supports revising systems and processes in an effort to narrow the difficult safety and quality gaps. Worldwide, issues of patient safety and patient-centered quality care drive health care reform. Current approaches are not adequate; patients remain at risk for needless harm.

Demonstrating a firm understanding of the various components of patient safety is fundamental to understanding health care quality, risk management, and patient safety overall.

For this first assessment, you will assume the role of a patient safety officer at your local hospital. You will analyze a patient safety issue that occurred and then prepare a five- to seven-page recommendation for senior leaders about why it is important to address the issue, along with your recommendations about how to address it. You will also need to detail the role you as the patient safety officer will play in helping the organization resolve the issue.

Reference

Johnson, J. K., Haskell, H. W., & Barach, P. R. (2016). Case studies in patient safety. Burlington, MA: Jones & Bartlett Learning.

DEMONSTRATION OF PROFICIENCY

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

• Competency 1: Analyze the quality and performance improvement activities within the health care organization.
  • Recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.
• Competency 3: Analyze the importance of patient safety in health care.
  • Apply the health care safety imperative to a patient safety issue.
  • Evaluate the risk to patients, employees, and the organization if patient safety threats are not addressed.
  • Analyze regulatory agencies’ role and impact on organizations’ patient safety programs.
• Competency 4: Apply leadership strategies to quality improvement in a health care organization.
  • Analyze the patient safety officer’s role in implementing patient safety plans.
• Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals.
  • Write a clear, persuasive, organized recommendation plan that is generally free of errors and is reflective of professional communication in the health care field.
  • Provide citations and title and reference pages that conform to APA style and format.

PREPARATION

To help prepare for successfully completing this assessment:

• Select one of the three scenarios from the Vila Health: Patient Safety simulation activity that interests you the most for further analysis in your assessment:
  • Scenario 1: Patient Identification Error.
  • Scenario 2: Medication Error.
  • Scenario 3: HIPAA/Privacy Violation.

INSTRUCTIONS

For the scenario you selected, write a five- to seven-page recommendation for leadership that describes the safety threat, the importance of addressing the threat, and your recommendations for resolving it. Be sure to include all of these headings in your paper and to address all of the bullets underneath each heading:

• Potential threat to patient safety:
  • Identify the issue you selected from the simulation activity as the potential safety threat.
  • Describe the issue that occurred with sufficient detail so that leadership has a clear understanding of what happened.
• Implications of not addressing threat:
  • Evaluate the risk to the organization if this issue is not addressed. In your evaluation, be sure to address all of the following:
    • What does the health care safety imperative say about the issue?
    • How does the health care safety imperative apply in this case?
    • Which regulatory agency(ies) have oversight about the issue?
    • What specifically do the regulation(s) state about the issue? For example, you might consider the Joint Commission’s national patient safety goals.
    • What impact do regulatory agencies have on organizations’ patient safety programs?
    • How do health care organizations incorporate regulatory agencies’ guidance when establishing reporting and investigation best practices?
    • If the hospital fails to correct the threat, what are the potential consequences to patients, employees, and to the organization?
• Patient safety officer’s role in effective implementation of patient safety plans:
  • Explain the role patient safety officers assume in implementing patient safety plans in health care organizations.
  • Clarify your responsibility and role as the patient safety officer in this specific instance.
  • Provide one example from the literature to illustrate your points.
• Recommendations to reduce patient safety threat:
  • Describe your five-point plan to reduce or eliminate this patient safety threat.
    • What best practice tools or techniques does your plan include to reduce or eliminate these types of errors? Consider processes for responding, rounding, detecting, incident reporting, operational considerations, et cetera.

In a health care professional setting, recommendations to leadership would typically not be in APA format. As a result, your paper does not need to conform to APA format and style guidelines. It does, however, need to be clear, persuasive, organized, and well written without spelling, grammar, and/or punctuation errors. In addition, recommendations you write in a professional setting would be single-spaced. For the purpose of this assessment, however, please use double-spacing.

Also, health care is an evidence-based field. Your senior leaders will want to know the sources of your information, so be sure to include at least two peer-reviewed sources. You may use the suggested resources for this assessment. Your citations and references do need to conform to APA guidelines.

ADDITIONAL REQUIREMENTS

• Length: Your recommendation will be 5–7 double-spaced pages, not including title and reference pages.
• Font: Times New Roman, 12-point.
• APA Format: Your title and reference pages need to conform to APA format and style guidelines. The body of your paper does not need to conform to APA guidelines. Do make sure that it is clear, persuasive, organized, and well written, without grammatical, punctuation, or spelling errors. You also must cite your sources according to APA guidelines.
• Scoring Guide: Please review this assessment’s scoring guide to ensure you understand how your faculty member will evaluate your work.

Address a Patient Safety Issue Scoring Guide

BHAFPX 4004 CU Analysis and Application of Dashboard Data PowerPoint

Create a presentation (maximum of 20 slides with detailed speaker notes) for senior leadership in which four organizational leaders analyze the impact of a health care organization’s new safety and quality dashboard. Include an analysis of what the new metrics mean and how they will inform departmental activities for the next quarter.”Being in a position of leadership is the most important job of any health professional anywhere along the continuum of care” (Ledlow & Coppola, 2013, p. 3).

Leaders and ultimately the boards of directors of health care organizations are accountable for the safety of those they serve.” National quality organizations and regulatory bodies … are growing in their emphasis on leadership accountabilities for safe, reliable care as well as excellence in the experience of care” (Youngberg, 2013, p. 39).

With this emphasis on leadership accountability for the delivery of safe, high-quality health care services, health care leaders need to be able to drill down on what exactly safety and quality mean in the health care environment. Likewise, they also need to be able to design measures that help to ensure their organizations are able to deliver those kinds of outcomes. Read Measurement Perspectives [PDF] to examine key elements related to this issue.

In this final course assessment, you will have a unique opportunity to examine a health care organization’s safety and quality dashboard from the perspective of four organizational leaders. You will explore each leader’s specific interests regarding patient safety and quality. In particular, you will have the opportunity to perform a more in-depth analysis of the dashboard, the type of analysis a quality director might perform to further the organization’s safety and quality objectives.

References

Ledlow, G. R., & Coppola, M. N. (2013). Leadership for health professionals (2nd ed.). Burlington, MA: Jones & Bartlett Learning.Youngberg, B. J. (2013). Patient safety handbook (2nd ed.). Burlington, MA: Jones & Bartlett Learning.

DEMONSTRATION OF PROFICIENCY

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

• Competency 1: Analyze the quality and performance improvement activities within the health care organization.
  • Recommend evidence-based actions to improve a selected measure on a health care organization’s safety and quality dashboard.
• Competency 2: Explain the risk management function in the health care organization.
  • Analyze areas of a safety and quality dashboard of concern to a risk manager.
• Competency 3: Analyze the importance of patient safety in health care.
  • Describe how a health care organization chooses the metrics to include in its safety and quality dashboard.
  • Analyze areas of a safety and quality dashboard of concern to a patient safety officer.
• Competency 4: Apply leadership strategies to quality improvement in a health care organization.
  • Assess senior leadership’s role in setting a health care organization’s strategic safety and quality objectives.
• Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals.
  • Create a clear, organized, persuasive, and generally error-free presentation on a leadership team’s assessment of an organization’s safety and quality dashboard that is reflective of professional communication in the health care field.
  • Provide citations and title and reference pages that conform to APA style and format.

PREPARATION

To help prepare for successfully completing this assessment:

• Download the Sample Presentation Guide [PPTX]. Use this as a starting point or guide as you develop your presentation.

INSTRUCTIONS

Your organization has just updated its safety and quality dashboard. Please review the Vila Health Mercy Hospital Safety and Quality Dashboard [PDF]. Note: You do not need to create a dashboard for this assessment. You are simply being asked to work with the one provided.The CEO has asked each of the organizational leaders below to prepare a joint PowerPoint presentation. In it, they are to prepare a set of slides outlining their analysis of how the new numbers will inform their particular activities for the next quarter. The organizational leaders include:

• The quality director.
• The patient safety officer.
• The risk manager.
• Senior leadership.

Because of the quality director’s critical role in implementing the organization’s safety and quality strategic objectives, this individual will open the presentation and provide additional background about how the new dashboard was developed. This individual will also close the presentation. Use the following outline to organize your presentation. Be sure to include the introduction and conclusion and address all the questions listed under these headings. Also be sure to address each role and the corresponding questions.

Introduction (3–4 slides)

• What is a safety and quality dashboard?
• What role do safety and quality dashboards play in helping health care organizations drive their strategic safety and quality objectives?
• How do health care organization determine what they want to measure? Be sure to consider:
  • Pressures from regulators, payors, and the industry.
  • Self-identified improvement areas. For example, one organization’s safety and quality dashboard may highlight patient falls because its rate of falls is higher than the national average. This may also have resulted in increased costs to the organization.
• What CQI tools did the organization use to obtain, measure, and report data?
• What was the quality improvement team’s role in addressing the reported measures?

Quality Director (2–3 slides)

• Which metric on the dashboard would draw the quality director’s attention the most?
• What does this dashboard metric mean and why is it important?
• What three recommendations to leadership would help to address this metric?
• What (if any) quality models could be used to increase the quality of patient care and outcomes for this metric? Consider PDCA, Six Sigma, Lean, Hoshin Kanri planning, et cetera.

Patient Safety Officer (2–3 slides)

• Which metric on the dashboard would draw the patient safety officer’s attention the most?
• What does this dashboard metric mean and why is it important?
• What role does the patient safety officer play in improving this metric?

Risk Manager (2–3 slides)

• Which metric on the dashboard would draw the risk manager’s attention the most?
• What does this dashboard metric mean and why is it important?
• What role does the risk manager play in improving this metric?

Senior Leader (1 slide)

• What is the role of senior leadership (for example, CEO, COO, president, senior VP) in driving safety and quality improvement initiatives?
• What next steps might senior leadership take given the dashboard findings and the quality director’s three improvement recommendations?

Conclusion (2–3 slides)

• Which regulatory agency(ies) may be concerned about the findings in this dashboard?
• Why would regulators be concerned about these findings?
• Why are safety and quality dashboards important for monitoring key metrics in health care organizations?

Your slides need to be concise and offer main ideas in bulleted format. Use the speaker notes to expand upon your findings as if they were the transcript of your presentation for the leadership team.In the health care environment, it is unlikely for a presentation and speaker notes to be in APA style. Do make sure they are concise, organized, clear, and free of errors in grammar, punctuation, and spelling. Do make sure they address all the required headings and all of the questions under each heading.Your senior leaders will want to know the sources of your information. Be sure to cite your sources in APA style in your speaker notes.

ADDITIONAL REQUIREMENTS

• • Presentation length: Your presentation should be a maximum of 20 slides, including title and reference slides. Format your title and reference slides according to APA format.
  • Speaker notes: Be sure to include these with your slides. They provide an opportunity for you to expand on the information you are highlighting in your slides.
  • Number of references: Cite a minimum of two references.
  • Scoring Guide: Please read the scoring guide for this assessment so you understand how your faculty member is going to evaluate your work.

Analyze and Apply Dashboard Data Scoring Guide

BHAFPX 4004 CU Issue Analysis and Leadership Action Plan for Medical Center Paper

Prepare an issue analysis of an incident that occurred in a health care organization and create a leadership action plan (8-10 pages) that will help to address the specific incident but will also help to drive safety and quality improvements throughout the organization.

In this third assessment in the course, you will assume the role of a newly promoted quality manager at your local hospital. This role requires you to address deficiencies by improving organizational culture, providing leadership oversight, and cultivating staff relationships within the organization. While you have many priorities in this new role, one of your first is to analyze a recent incident that occurred within the organization and to create a leadership action plan with recommended strategies and tactics to address not just the specific incident, but to drive safety and quality improvement throughout the organization.

This assessment differs from the first assessment in that with this assessment, as the quality manager, your focus is broader. Rather than focusing only on identifying specific actions the organization can take to remedy a particular incident that occurred, you are concentrating on what steps you will take as the quality manager to influence the organization’s leadership to cultivate a fair and just culture.

You will determine what departments, what leaders, and what personnel you will collaborate with to improve quality for the whole organization. In this type of culture, safety is at the forefront of everyone’s job and all associates welcome the opportunity to highlight issues—without fear of reprisal—so that they can be addressed at a systemic level throughout the organization.

You may find it useful to review the short document CQI Importance and Features [PDF] as you gather your thoughts about the key elements you want to include in your assessment, Issue Analysis and Leadership Action Plan.

DEMONSTRATION OF PROFICIENCY

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

• Competency 4: Apply leadership strategies to quality improvement in a health care organization.
  • Apply the IHI Triple Aim to develop a health care leadership strategy that focuses on optimizing health care system performance.
  • Propose evidence-based leadership strategies that will help to establish a safety and quality culture.
  • Propose evidence-based leadership and collaboration strategies to enlist the aid of key organizational leaders in establishing a safety and quality culture.
  • Determine opportunities to enlist the governing board’s aid in fostering a fair and just culture.
• Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals.
  • Write a clear, organized, persuasive, and generally error-free issue analysis and leadership action plan that promotes a culture of safety and quality and is reflective of professional communication in the health care field.
  • Provide citations and title and reference pages that conform to APA style and format.

PREPARATION

To help prepare for successfully completing this assessment:

• Select one of the three incidents from the Vila Health: Patient Safety simulation you completed in Assessment 1. These are common incidents you are likely to encounter in the health care field. These included a patient identification error, a medication error, and a HIPAA/privacy violation. You may select one of the incidents you worked with in the previous assessments or select another one. Pick one that holds the most interest for you.
• Consider these analysis questions once you have selected the incident on which you will focus:
  • What information do you possess about the issue? (Note: You may not be able to answer all of these questions; just include the information you know.) Consider:
    • Who was involved?
    • During what process (clinical, communication, operational) did the issue occur?
    • When did the issue occur? During a particular shift? On a particular day? During peak hours? Under certain clinical circumstances?
    • Where did the issue occur?
  • What additional data about the incident would you like to collect and analyze?
  • Which best practices may not have been adhered to that may have contributed to the issue? (Note: This information will prove useful to you as you complete your analysis and leadership action plan.)

INSTRUCTIONS

Write an analysis and leadership action plan for the issue you selected that will enable you to address the issue on an organization-wide basis. Please make sure to include all of the following headings and answer all of the questions underneath each heading.

Issue Summary

• How would you summarize the key elements of the incident that occurred?
• What is your goal in addressing the issue?
• Which two to three key items will be your focus? For example, you may elect to focus on nursing staffing levels if being short staffed in nursing is contributing to compromises to patient safety.

IHI Triple Aim

• What is the IHI Triple AIM?
• How does the IHI Triple Aim apply to this specific incident?
• What IHI Triple Aim elements will you incorporate into your organizational improvement strategy?

Culture

• What is culture?
• Why is culture a critical organizational priority for safety and quality?
• Based on the knowledge you have about the selected issue, what do you know about the existing organizational culture?
• What are some of the evidence-based strategies you are considering you could employ to cultivate a culture of safety?

Collaboration

• Which key departments need to be directly involved with the corrective action process?
• What is your rationale for selecting these departments? For example, you may want to involve nursing because many of errors involve nurses and obtaining their buy-in is critical to achieving the organizational priority.
• Which specific senior leader, front line staff member, and clinical expert will you include in your action plan and hold accountable for implementation?
• What are the implications of not engaging with all departments toward making safety and quality top of mind?
• How might you involve other departments in addressing the specific issue and the cultural issue?

Leadership

• Which specific leaders within the organization could assist you in addressing this issue and in making patient safety and quality top of mind throughout the organization? Examples for you to consider include the chief nursing officer, the chief medical officer, the patient safety officer, et cetera.
• What role do you expect these leaders to play in addressing the specific issue and the issue of culture?
• What best practices would you employ to enlist their aid in the improvement effort?
• What role does the organization’s governing board have in terms of quality and safety in the organization?
• How could you enlist the governing board’s aid in your improvement initiative?
• What additional information could you provide them to increase their involvement in the organization’s safety and quality improvement efforts?

Leadership Action Plan

• What are three evidence-based actions you recommend that would help to solve the incident that arose?
• What are three evidence-based best practices you recommend to address the issue on an organizational level?

Conclusion

• How will you summarize your analysis of the incident and your leadership action plan?

Remember that health care is an evidence-based field. You will need to cite a minimum of two credible references to support your analysis and action planning process.

In addition, in the health care field, your analysis and action plan would not typically be written in APA format. Do ensure that it is clear, persuasive, concise, organized, and without errors in grammar, punctuation, and spelling. Do provide citations and title and reference pages in APA format. Other leaders in your organization are going to want to know what sources you relied on to prepare your analysis and action plan.

ADDITIONAL REQUIREMENTS

• Length: Your incident analysis and leadership action plan will be 8–10 double-spaced pages, not including title and reference pages.
• Font: Times New Roman, 12-point.
• APA Format: Your citations and title and reference pages need to be in APA format. The body of your analysis does not need to be written in APA format. It does need to be well written, include the headings specified in the instructions, and address the questions listed under each heading.
• Scoring Guide: Please review this assessment’s scoring guide to ensure you understand how your faculty member will evaluate your work.P

Prepare an issue analysis of an incident that occurred in a health care organization and create a leadership action plan (8-10 pages) that will help to address the specific incident but will also help to drive safety and quality improvements throughout the organization.

In this third assessment in the course, you will assume the role of a newly promoted quality manager at your local hospital. This role requires you to address deficiencies by improving organizational culture, providing leadership oversight, and cultivating staff relationships within the organization. While you have many priorities in this new role, one of your first is to analyze a recent incident that occurred within the organization and to create a leadership action plan with recommended strategies and tactics to address not just the specific incident, but to drive safety and quality improvement throughout the organization.

This assessment differs from the first assessment in that with this assessment, as the quality manager, your focus is broader. Rather than focusing only on identifying specific actions the organization can take to remedy a particular incident that occurred, you are concentrating on what steps you will take as the quality manager to influence the organization’s leadership to cultivate a fair and just culture. You will determine what departments, what leaders, and what personnel you will collaborate with to improve quality for the whole organization.

In this type of culture, safety is at the forefront of everyone’s job and all associates welcome the opportunity to highlight issues—without fear of reprisal—so that they can be addressed at a systemic level throughout the organization. You may find it useful to review the short document CQI Importance and Features [PDF] as you gather your thoughts about the key elements you want to include in your assessment, Issue Analysis and Leadership Action Plan.

DEMONSTRATION OF PROFICIENCY

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

• Competency 4: Apply leadership strategies to quality improvement in a health care organization.
  • Apply the IHI Triple Aim to develop a health care leadership strategy that focuses on optimizing health care system performance.
  • Propose evidence-based leadership strategies that will help to establish a safety and quality culture.
  • Propose evidence-based leadership and collaboration strategies to enlist the aid of key organizational leaders in establishing a safety and quality culture.
  • Determine opportunities to enlist the governing board’s aid in fostering a fair and just culture.
• Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals.
  • Write a clear, organized, persuasive, and generally error-free issue analysis and leadership action plan that promotes a culture of safety and quality and is reflective of professional communication in the health care field.
  • Provide citations and title and reference pages that conform to APA style and format.

PREPARATION

To help prepare for successfully completing this assessment:

• Select one of the three incidents from the Vila Health: Patient Safety simulation you completed in Assessment 1. These are common incidents you are likely to encounter in the health care field. These included a patient identification error, a medication error, and a HIPAA/privacy violation. You may select one of the incidents you worked with in the previous assessments or select another one. Pick one that holds the most interest for you.
• Consider these analysis questions once you have selected the incident on which you will focus:
  • What information do you possess about the issue? (Note: You may not be able to answer all of these questions; just include the information you know.) Consider:
    • Who was involved?
    • During what process (clinical, communication, operational) did the issue occur?
    • When did the issue occur? During a particular shift? On a particular day? During peak hours? Under certain clinical circumstances?
    • Where did the issue occur?
  • What additional data about the incident would you like to collect and analyze?
  • Which best practices may not have been adhered to that may have contributed to the issue? (Note: This information will prove useful to you as you complete your analysis and leadership action plan.)

INSTRUCTIONS

Write an analysis and leadership action plan for the issue you selected that will enable you to address the issue on an organization-wide basis. Please make sure to include all of the following headings and answer all of the questions underneath each heading.

Issue Summary

• How would you summarize the key elements of the incident that occurred?
• What is your goal in addressing the issue?
• Which two to three key items will be your focus? For example, you may elect to focus on nursing staffing levels if being short staffed in nursing is contributing to compromises to patient safety.

IHI Triple Aim

• What is the IHI Triple AIM?
• How does the IHI Triple Aim apply to this specific incident?
• What IHI Triple Aim elements will you incorporate into your organizational improvement strategy?

Culture

• What is culture?
• Why is culture a critical organizational priority for safety and quality?
• Based on the knowledge you have about the selected issue, what do you know about the existing organizational culture?
• What are some of the evidence-based strategies you are considering you could employ to cultivate a culture of safety?

Collaboration

• Which key departments need to be directly involved with the corrective action process?
• What is your rationale for selecting these departments? For example, you may want to involve nursing because many of errors involve nurses and obtaining their buy-in is critical to achieving the organizational priority.
• Which specific senior leader, front line staff member, and clinical expert will you include in your action plan and hold accountable for implementation?
• What are the implications of not engaging with all departments toward making safety and quality top of mind?
• How might you involve other departments in addressing the specific issue and the cultural issue?

Leadership

• Which specific leaders within the organization could assist you in addressing this issue and in making patient safety and quality top of mind throughout the organization? Examples for you to consider include the chief nursing officer, the chief medical officer, the patient safety officer, et cetera.
• What role do you expect these leaders to play in addressing the specific issue and the issue of culture?
• What best practices would you employ to enlist their aid in the improvement effort?
• What role does the organization’s governing board have in terms of quality and safety in the organization?
• How could you enlist the governing board’s aid in your improvement initiative?
• What additional information could you provide them to increase their involvement in the organization’s safety and quality improvement efforts?

Leadership Action Plan

• What are three evidence-based actions you recommend that would help to solve the incident that arose?
• What are three evidence-based best practices you recommend to address the issue on an organizational level?

Conclusion

• How will you summarize your analysis of the incident and your leadership action plan?

Remember that health care is an evidence-based field. You will need to cite a minimum of two credible references to support your analysis and action planning process.In addition, in the health care field, your analysis and action plan would not typically be written in APA format. Do ensure that it is clear, persuasive, concise, organized, and without errors in grammar, punctuation, and spelling. Do provide citations and title and reference pages in APA format. Other leaders in your organization are going to want to know what sources you relied on to prepare your analysis and action plan.

ADDITIONAL REQUIREMENTS

• • Length: Your incident analysis and leadership action plan will be 8–10 double-spaced pages, not including title and reference pages.
  • Font: Times New Roman, 12-point.
  • APA Format: Your citations and title and reference pages need to be in APA format. The body of your analysis does not need to be written in APA format. It does need to be well written, include the headings specified in the instructions, and address the questions listed under each heading.
  • Scoring Guide: Please review this assessment’s scoring guide to ensure you understand how your faculty member will evaluate your work.

Collaborate on Quality Issue Analysis and Leadership Action Plan Scoring Guide