Prepare an issue analysis of an incident that occurred in a health care organization and create a leadership action plan that will help to address the specific incident but will also help to drive safety and quality improvements throughout the organization. The issue analysis and action plan together should be 8-10 pages.
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Introduction
The quality manager at any hospital is required to address deficiencies by improving organizational culture, providing leadership oversight, and cultivating staff relationships within the organization. This role has many priorities. For example, a quality manager is tasked with analyzing any incidents that occur within the organization and creating 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.
The following assessment differs from the first two assessments in that, acting 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. What departments, leaders, and personnel will you 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.
Preparation
To successfully complete this assessment, use the Collaborate on Quality Template [DOC] to address the following:
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. You may select one of the incidents you worked with in the previous assessments or select a different one. Choose the one that holds the most interest to you. These incidents included:
A patient identification error.
A medication error.
A HIPAA/privacy violation.
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 lapse in best practices may have contributed to the issue? (Note: This information will prove useful to you as you complete your analysis and leadership action plan.)
Review the Collaborate on Quality Template [DOC], which you will use to complete this assessment. This document is formatted and has space for completing all components of the assessment.
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.
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: Explain what culture is and why it is a critical priority for safety and quality, providing at least two evidence-based strategies for cultivating a culture of safety.
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: Apply the IHI Triple Aim to develop a health care leadership strategy that focuses on optimizing health care system performance.
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: Propose evidence-based leadership and collaboration strategies to enlist the aid of key organizational leaders in establishing a culture of safety and quality.
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 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?
Leadership Action Plan: Create an evidence-based action plan that includes leadership strategies to establish a culture of safety and quality.
What are three evidence-based—meaning supported by current literature—leadership strategies 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: Determine opportunities to enlist the governing board’s aid in fostering a fair and just culture.
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?
In addition, your assessment needs to conform to current APA style and format guidelines. Ensure that it is clear, persuasive, concise, organized, and without errors in grammar, punctuation, and spelling. 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.
Note: 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.
Please review the Collaborating on Quality: Issue Analysis and Leadership Action Plan Scoring Guide to ensure you understand the grading requirements for this assessment.
Additional Requirements
Your assessment should also meet the following requirements:
Template: Use the Collaborate on Quality Template [DOC] to complete this assessment.
Length: 8–10 double-spaced pages, excluding 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—needs to be in APA format and style guidelines. It needs to be well-written, include the headings specified in the instructions, and address the questions listed under each heading.
