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.
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.)
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.
- 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?
- 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?
- 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?
- 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?
- 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.
- 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.
Kyra Dilley serves as the hospital’s patient safety officer. One of Kyra’s duties is to perform daily safety rounds. One week ago, Kyra did a round at the pediatric unit on the 8th floor. When doing this, she noticed that there were two patients in rooms directly across from each other who had similar names. These patients were B.R. Moore and B. Moore. B. Moore’s birthday was 8/11/05, and B. R. Moore was 11/8/05. Despite measures to prevent patient identification errors, a medication error occurred a week later involving B. Moore. To make matters worse, one day after this mistake, B. Moore’s mother, while signing in at the front desk, overheard an inappropriate conversation between the unit secretary (Ida Feeney) and a nurse