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.)
- 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:
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.
ACTIVITY (MEDICATION ERROR WAS CHOSEN FOR PREVIOUS ASSIGNMENTS)
Introduction
Independence Medical Center is a rural referral hospital with 115 beds in Independence, Iowa. Like all hospitals, administrators and providers try to avoid errors, and it’s the patient safety officer’s role to monitor the hospital’s safety posture and recommend better practices. But what happens when a mistake leads to a medication error?
Patient Identification
At Independence Medical Center, the patient safety officer conducts daily safety rounds. Today, she’s rounding at the pediatric unit on the eighth floor.
Kyra Dilley and Virginia Anderson
Kyra Dilley: Hi, where’s the charge nurse?
Virginia Anderson: That’s me. What’s up?
Kyra Dilley: Well, I’m doing my safety rounds and I noticed that there are two patients on this floor in rooms directly across from each other: B. Moore and B.R. Moore.
Virginia Anderson: That’s not all — they have really similar birthdates! B. Moore was born on 8/11/05 and B. R. on 11/8/05.
Kyra Dilley: Okay, that’s even more concerning. How are you making sure not to confuse those patients?
Virginia Anderson: It’s not a problem. We’re making sure that the two patients always have different nurses.
Kyra Dilley: Well, that’s good, but I have to warn you that this is a troubling situation. Are all shifts aware of the need to schedule nurses around this?
Virginia Anderson: There are notes in both charts. We had to do that; we’ve been short staffed this week and there’s been a lot of shifting around.
Medication Error
Later that week, the PSO gets a call from the hospital’s risk manager.
Kyra Dilley and Arthur Chester
Kyra Dilley: This is Kyra Dilley.
Arthur Chester: Hi, Kyra, this is Arthur Chester. I’m calling to let you know about a medication error on the eighth floor.
Kyra Dilley: Oh, no. Was it B. Moore or B.R. Moore?
Arthur Chester: How did you know? It was B. Moore, birthdate 8/11/05. My investigation isn’t complete but there were two patients with similar names and birthdates in rooms in close proximity.
Kyra Dilley: Okay. Have you interviewed the nurses involved yet? There should have been different nurses for each patient.
HIPAA
The day after the medication error, B. Moore’s mother signs in at the front desk to get her visitation pass. As she is standing at the front desk, she overhears an inappropriate conversation between Ida Feeney, the unit secretary, and a nurse from a different unit of the hospital.
Ida Feeney and Brenda Turner
Ida Feeney: Did you hear about the Moore kid? It’s a good thing they caught that right away. She’s small for her age, and that insulin could have really done a number on her.
Brenda Turner: Jeez, how much did they give her?
Ida Feeney: Well, she wasn’t supposed to have any. But I forget the actual dose. I’ll look in the EHR later, but I think it was pretty high.
Brenda Turner: Wait, is it Belinda Moore?
Ida Feeney: Yes, why?
Brenda Turner: I think she’s in a gymnastics class with my daughters!
Scoring Guide
Apply the IHI Triple Aim to develop a health care leadership strategy that focuses on optimizing health care system performance.
Does not apply the IHI Triple Aim to develop a health care leadership strategy that focuses on optimizing health care system performance.
Attempts to apply the IHI Triple Aim to develop a health care leadership strategy that focuses on optimizing health care system performance; however, omissions and/or errors exist.
Applies the IHI Triple Aim to develop a health care leadership strategy that focuses on optimizing health care system performance.
Applies the IHI Triple Aim to develop a health care leadership strategy that focuses on optimizing health care system performance. Narrative includes multiple examples, specifics, and references to the professional literature.
Propose evidence-based leadership strategies that will help to establish a safety and quality culture.
Does not propose evidence-based leadership strategies that will help to establish a safety and quality culture.
Attempts to propose evidence-based leadership strategies that will help to establish a safety and quality culture, but strategies are not always evidence based or appropriate. Omissions and/or errors exist.
Proposes evidence-based leadership strategies that will help to establish a safety and quality culture.
Proposes multiple evidence-based leadership strategies that will help to establish a safety and quality culture. Includes multiple examples, specifics, and references to the professional literature.
Propose evidence-based leadership and collaboration strategies to enlist the aid of key organizational leaders in establishing a safety and quality culture.
Does not propose evidence-based leadership and collaboration strategies to enlist the aid of key organizational leaders in establishing a safety and quality culture.
Attempts to propose evidence-based leadership and collaboration strategies to enlist the aid of key organizational leaders in establishing a safety and quality culture; however, strategies are not always evidence-based or appropriate. Omissions and/or errors exist.
Proposes evidence-based leadership and collaboration strategies to enlist the aid of key organizational leaders in establishing a safety and quality culture.
Proposes multiple evidence-based leadership and collaboration strategies to enlist the aid of key organizational leaders in establishing a safety and quality culture. Includes multiple examples, specifics, and references to the professional literature.
Determine opportunities to enlist the governing board’s aid in fostering a fair and just culture.
Does not determine opportunities to enlist the governing board’s aid in fostering a fair and just culture.
Attempts to determine opportunities to enlist the governing board’s aid in fostering a fair and just culture; however, omissions and/or errors exist.
Determines opportunities to enlist the governing board’s aid in fostering a fair and just culture.
Determines multiple opportunities to enlist the governing board’s aid in fostering a fair and just culture. Includes multiple examples, specifics, and references to the professional literature.
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.
Does not 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.Attempts to write a clear, organized, persuasive, and generally error-free issue analysis and leadership action plan that promotes a culture of safety and is reflective of professional communication in the health care field; however, lapses, omissions, and/or errors exist.Writes 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.Writes a clear, organized, persuasive and error-free incident analysis and leadership action plan that is reflective of professional communication in the health care field. Narrative includes multiple relevant examples, specifics, and references to the professional literature.
Provide citations and title and reference pages that conform to APA style and format.
Does not provide citations and title and reference pages that conform to APA style and format.
Attempts to provide citations and title and reference pages that conform to APA style and format; however, omissions and/ errors exist.
Provides citations and title and reference pages that conform to APA style and format.
Provides citations and title and reference pages that conform to APA style and format, without errors.
SUGGESTED TO READ
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 plan.
• A quality council made up of the institution’s top leadership.
• Training programs for personnel.
• Mechanisms for selecting improvement opportunities.
• Formation of process improvement teams.
• Staff support for process analysis and redesign.
• Personnel policies that motivate and support staff participation in process
improvement.
• Application of the most current and rigorous techniques of the scientific method
and statistical process control.
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).
2
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
