MUST BE SPECIFIC AND INCLUDE AT LEAST 2-3 SPECIFIC EXAMPLES THAT ARE CITED IN THE TEXT

MUST USE HEADINGS

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.

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 PER ISSUES AND USE HEADINGS