BHA4004 Capella University Hospital Issue Analysis and Leadership Action Plan Paper

BHA4004 Hospital Issue Analysis and Leadership Action Plan Paper Capella University

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).

BHA4004 Hospital Issue Analysis and Leadership Action Plan Paper Capella University

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, N. D. M., 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.

Collaborating on Quality: Issue Analysis and Leadership Action Plan

Introduction

In this third assignment 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 assignment differs from the first two assignments in that with this, 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 Importance and Features of Continuous Quality Improvement (CQI) (given in the resources) as you gather your thoughts about the key elements you want to include in this assignment.

Demonstration of Proficiency: BHA4004 Hospital Issue Analysis and Leadership Action Plan Paper Capella University

By successfully completing this assignment, you will demonstrate proficiency in the following course competencies. Refer to the scoring guide for further details.

• Competency 4: Apply leadership strategies to quality improvement in a health care organization.
• Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with the expectations for health care professionals.

Summary

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.

Preparation

To successfully complete this assignment:

• Select one of the three incidents from the Vila Health: Patient Safety simulation. 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 assignments or select another one. Choose one that holds the most interest for you.
• Consider the following 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, or 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.)
• Consult the readings listed in the assignment preparation study in Unit 6.
• Review the Assignment 3 template (provided in the resources), which you will use to complete this assignment. This document is formatted and has space for completing all components of the assignment.

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.

Introduction: Issue Summary

Address the following:

• How would you summarize the key elements of the incident that occurred?
• What is your goal in addressing the issue?
• Which 2–3 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.

Culture

Address the following:

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

IHI Triple Aim

Address the following:

• 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?

Leadership and Collaboration

Address the following:

• 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?

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: BHA4004 Hospital Issue Analysis and Leadership Action Plan Paper Capella University

Leadership Action Plan

Address the following:

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

Opportunities to Enlist Governing Board

Address the following:

• 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?

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, your assignment needs to conform to current APA style and format guidelines. 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 current 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.

Please review the Collaborating on Quality: Issue Analysis and Leadership Action Plan Scoring Guide to ensure you understand the grading requirements for this assignment.

Additional Requirements

Your assignment should also meet the following requirements:

• Template: Use the Assignment 3 template (provided in the resources) to complete this assignment.
• Length: 8–10 double-spaced pages, not including title and reference pages.
• Font and font size: Times New Roman, 12 point.
• APA format: Your submission, including the body, citations, and title and reference pages need to be in APA format and style guidelines. It does need to be well written, include the headings specified in the instructions, and address the questions listed under each heading.

Issue Summary

[Summarize the key elements of the incident that occurred. Discuss your goals in addressing the issue. Discuss 2–3 items that will be your focus. Delete all statements within brackets, such as this paragraph, and replace with your discussion. Also, before you begin, review the “Scoring Guide” and understand the difference between “Distinguished,” “Proficient,” “Basic,” and “Non-Performance.” These “Scoring Guides” are used to grade the assignment. This is why each template is set up with headings (below) that correspond with the “Scoring Guides” for this specific assignment. Please leave the Headings (below) in the paper.]

Culture

[Discuss what culture is and why it is a critical organizational priority for safety and quality. Discuss what you know about the existing organizational culture (based on the knowledge you have about the selected issue). Discuss what some of the evidence-based strategies you are considering to cultivate a culture of safety.]

IHI Triple Aim

[What is the IHI Triple Aim? Discuss how the IHI Triple Aim applies to this specific incident. Describe what IHI Triple Aim elements you will incorporate into your organizational improvement strategy.]

Evidence-Based Leadership and Collaboration Strategies

[Discuss the following: Which key departments need to be directly involved with the corrective action process? What is your rationale for selecting these departments? 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?]

Leadership Action Plan

[Recommend three evidence-based actions that would help to establish a safety and quality culture. Propose three evidence-based best practices you would recommend to address the issue on an organizational level.]

Opportunities to Enlist Governing Board

[Discuss the role the governing board has in terms of quality and safety in the organization. Describe how you would enlist the governing boards aid in your improvement initiative. Discuss any additional information you could provide to the governing board to increase their involvement in the organization’s safety and quality improvement efforts.]

Conclusion

[Summarize your analysis of the incident and your leadership action plan.]

References

[Lastname, C. (2008). Title of the source without caps except Proper Nouns or: First word after colon. The Journal or Publication Italicized and Capped, Vol# (Issue#), Page numbers.

Lastname, O. (2010). Online journal using DOI or digital object identifier. Main Online Journal Name, Vol#(Issue#), 159–192. doi: 10.1000/182

Lastname, W. (2009). If there is no DOI use the URL of the main website referenced. Article Without DOI Reference, Vol#(Issue#), 166–212. Retrieved from http://www.mainwebsite.org

NOTE: The above references are SAMPLES ONLY. For more information and example related to references, visit Capella’s Writing Center. YOU ARE RESPONSIBLE FOR SUBMITTING APPROPRIATE IN-TEXT AND REFERENCE PAGE CITATIONS.]

• RESOURCES

• COLLABORATION AND TEAMWORK

  • ASQ. (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-ethics
  • U.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 work

• THE IHI TRIPLE AIM

  You 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 TOOLS

  • CQI 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.

• • CULTURE

    • 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.
    • 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…

There is nothing novel or cutting edge about statistics, the field dates back hundreds of years. The first known evidence of the notion of social statistics dates back to the 1600s and was comprised of documented conversations about probability and formulae for normal curves (Fienberg, 1992). The collection, organization, and statistical examination of patient information are the cornerstones of nursing practice. Florence Nightingale was a statistician who gathered data on injured troops. This data included information on

PLACE THIS ORDER OR A SIMILAR ORDER WITH SUPERIOR NURSING PAPERS TODAY AND GET AN AMAZING DISCOUNT