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:
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
IHI Triple Aim
Culture
Collaboration
Leadership
Leadership Action Plan
Conclusion
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
Collaboration and TeamworkASQ. (n.d.). Teams. Retrieved from http://asq.org/learn-about-quality/teams/overview/…Berry, J. C., Davis, J. T., Bartman, T., Hafer, C. C., Lieb, L. M., Khan, N., & Brilli, R. J. (2016). Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system [PDF]. Journal of Patient Safety. Manuscript published ahead of print.Health Care Administration Undergraduate Library Research Guide.National Association for Healthcare Quality. (2011). NAHQ code of ethics and standards of practice. Retrieved from https://nahq.org/about/code-of-ethicsU.S. Department of Health and Human Services Health Resources and Services Administration. (n.d.). Improvement teams [PDF]. Retrieved from https://www.hrsa.gov/sites/default/files/quality/t…evaluate your workThe IHI Triple AimYou may find it useful to revisit these suggested resources from Assessment 1 on the IHI Triple Aim as you formulate your thinking around the IHI Triple Aim section of your analysis and leadership action plan:Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs, 27(3), 759–769.Institute for Healthcare Improvement. (2018). IHI triple aim initiative. Retrieved from http://www.ihi.org/Engage/Initiatives/TripleAim/Pa…Quality Improvement ToolsCQI Importance and Features [PDF].Gillam, S., & Siriwardena, A. N. (2013). Frameworks for improvement: Clinical audit, the plan-do-study-act cycle and significant event audit. Quality in Primary Care, 21(2), 123–130.Kovach, J. V., Revere, L., & Black, K. (2013). Error proofing healthcare: An analysis of low cost, easy to implement and effective solutions. Leadership in Health Services, 26(2), 107–117.Millar, R. (2013). Framing quality improvement tools and techniques in healthcare. Journal of Health Organization and Management, 27(2), 209–224.CultureBerry, J. C., Davis, J. T., Bartman, T., Hafer, C. C., Lieb, L. M., Khan, N., & Brilli, R. J. (2016). Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system [PDF]. Journal of Patient Safety. Manuscript published ahead of print.Frank-Cooper, M. (2014). The justice behind a just culture. Nephrology Nursing Journal, 41(1), 87–88.Miranda, S., Jr., & Olexa, G. A. (2013). Creating a just culture. Pennsylvania Nurse, 68(4), 4–10.Stevens, M. (2014). Just culture: A fairer way to improve care. Healthcare Leadership Review, 33(7), 8–10. Institute for Healthcare Improvement. (2015). What is a culture of safety? [Video] | Transcript. Retrieved from http://www.ihi.org/education/IHIOpenSchool/resourc…