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Homework: safety score improvement plan.

Homework: safety score improvement plan.

ORDER CUSTOM, PLAGIARISM-FREE PAPERS HERE  Homework: safety score improvement plan.

Consider the hospital-acquired conditions that are not reimbursed for under Medicare/Medicaid. Among these conditions are specific safety issues such as infections, falls, medication errors, and other safety concerns that could have been prevented or alleviated with the use of evidence-based guidelines. Hospital Safety Score, an independent nonprofit organization, uses national performance measures to determine the safety score for hospitals in the United States. The Hospital Safety Score Web site and other online resources provide hospital safety scores to the public.

Read the scenario below:

Scenario

As the manager of a unit, you have been advised by the patient safety office of an alarming increase in the hospital safety score for your unit. This is a very serious public relations matter because patient safety data is public information. It is also a financial crisis because the organization stands to lose a significant amount of reimbursement money from Medicare and Medicaid unless the source of the problem can be identified and corrected. You are required to submit a safety score improvement plan to the organization’s leadership and the patient safety office.

Select a specific patient safety goal that has been identified by an organization, or one that is widely regarded in the nursing profession as relevant to quality patient care delivery, such as patient falls, infection rates, catheter-induced urinary infections, IV infections, et cetera.

DELIVERABLE: SAFETY SCORE IMPROVEMENT PLAN

Develop a 3–5 page safety score improvement plan.

  • Identify the health care setting and nursing unit of your choice in the title of the mitigation plan. For example, “Safety Score Improvement Plan for XYZ Rehabilitation Center.”
  • You may choose to use information on a patient safety issue for the organization in which you currently work, or search for information from a setting you are familiar with, perhaps from your clinical work.
    • Demonstrate systems theory and systems thinking as you develop your recommendations.

Organize your report with these headings:

Study of Factors
  • Identify a patient safety issue.
  • Describe the influence of nursing leadership in driving the needed changes.
  • Apply systems thinking to explain how current policies and procedures may affect a safety issue.
Recommendations
  • Recommend an evidence-based strategy to improve the safety issue.
  • Explain a strategy to collect information about the safety concern.
    • How would you determine the sources of the problem?
  • Explain a plan to implement a recommendation and monitor outcomes.
    • What quality indicators will you use?
    • How will you monitor outcomes?
    • Will policies or procedures need to be changed?
    • Will nursing staff need training?
    • What tools will you need to do this?
Additional Requirements
  • Written communication: Written communication should be free of errors that detract from the overall message.
  • APA formatting: Resources and in-text citations should be formatted according to current APA style and formatting.
  • Length: The plan should be 3–5 pages.
  • Font and font size: Times New Roman, 12 point, double-spaced.
  • Number of resources: Use a minimum of three peer-reviewed resources.

Resources

SUGGESTED RESOURCES

The following optional resources are provided to support you in completing the assessment or to provide a helpful context. For additional resources, refer to the Research Resources and Supplemental Resources in the left navigation menu of your courseroom.

Capella Media

Click the link provided below to view the following multimedia piece:

SYSTEMS THEORY AND THE FIFTH DISCIPLINE

Intro

Peter Senge’s vision of a learning organization has been deeply influential. Self described as an idealistic pragmatist, Senge’s orientation allowed him to explore and advocate some utopian and abstract ideas—especially about systems theory and the necessity of bringing human values to the workplace. He was also able to translate these issues for application in very different organizations.

In The Fifth Discipline, Senge explains that systems thinking is particularly important because it connects the disciplines together and helps explain the complex behavior and outcomes that occur in organizations. It also illuminates feedback loops—growth cycles, control cycles, and delays that drive organizational systems. Senge’s book gives us a language for understanding these systems and explaining their dramatic successes and failures.

Senge’s second installment, The Fifth Discipline Fieldbook, is filled with practical tips and real-life examples from companies and organizations that have embraced organizational learning successfully. In this book, Senge asserts that the practice of organizational learning involves developing and taking part in tangible activities that will change the way people think and interact.

This presentation provides a high level overview to Senge’s five disciplines Click on each section to learn more about each discipline.

Personal Mastery

This discipline of aspiration involves formulating a coherent picture of the results people most desire to gain as individuals (their personal vision), alongside a realistic assessment of the current state of their lives today (their current reality). Learning to cultivate the tension between vision and reality (represented in this icon by the rubber band) can expand people’s capacity to make better choices, and to achieve more of the results that they have chosen.

Mental Models

This discipline of reflection and inquiry skills is focused around developing awareness of the attitudes and perceptions that influence thought and interaction. By continually reflecting upon, talking about, and reconsidering these internal pictures of the world, people can gain more capability in governing their actions and decisions. One example of this discipline is the “ladder of inference,” which depicts how people leap instantly to counterproductive conclusions and assumptions.

Shared Vision

This collective discipline establishes a focus on mutual purpose. People learn to nourish a sense of commitment in a group or organization by developing shared images of the future they seek to create and the principles and guiding practices by which they hope to get there.

Team Learning

This is a discipline of group interaction. Through techniques like dialogue and skillful discussion, teams transform their collective thinking, learning to mobilize their energies and ability greater than the sum of individual members’ talents.

Systems Thinking

In this discipline, people learn to better understand interdependency and change, and thereby to deal more effectively with the forces that shape the consequences of our actions. Systems thinking is based upon a growing body of theory about the behavior of feedback and complexity-the innate tendencies of a system that leads to growth or stability over time. Tools and techniques such as systems archetypes and various types of learning labs and simulations help people see how to change systems more effectively, and how to act more in tune with the larger processes of the natural and economic world.

REFERENCES

  • Senge, P. (1990). The fifth discipline: The art and practice of the learning organization. New York, New York: Currency Doubleday Publications.
  • Senge, P. (1994). The fifth discipline fieldbook. New York, New York: Currency Doubleday Publications.
  • Smith, M.K. (2001). Peter Senge and the learning organization. Retrieved July 15, 2008 from http://www.infed.org/thinkers/senge.htm
  • Society of Organizational Learning. (n.d.) The five disciplines of organizational learning. Retrieved July 15, 2008 from http://www.solonline.org/organizational_overview/

CREDITS

Subject Matter Expert:
John Herr
Interactive Designer:
Alyssa Wilcox
Instructional Designer:
Tiffany Herder
Project Manager:
Catherine Baumgartner

The following e-books or articles from the Capella University Library are linked directly in this course:Library Resources

Course Library Guide

A Capella University library guide has been created specifically for your use in this course. You are encouraged to refer to the resources in the BSN-FP4008 – Organizational and Systems Management for Quality Outcomes Library Guide to help direct your research.

Internet Resources

Access the following resources by clicking the links provided. Please note that URLs change frequently. Permissions for the following links have been either granted or deemed appropriate for educational use at the time of course publication.

Bookstore Resources

The resources listed below are relevant to the topics and assessments in this course and are not required. Unless noted otherwise, these materials are available for purchase from the Capella University Bookstore. When searching the bookstore, be sure to look for the Course ID with the specific –FP (FlexPath) course designation.

  • Huber, D. L. (2014). Leadership and nursing care management (5th ed.). Maryland Heights, MO: W. B. Saunders.
    • Chapter 24.
    • Chapter 25.
    • Chapter 34.
    • Chapter 36.

Context

Quality improvement and patient safety are health care industry imperatives (Institute of Medicine’s Committee on Quality of Health Care in America, 2001). Effective quality improvement results in system and organizational change. This ultimately contributes to the creation of a patient safety culture.

A landmark publication by the Institute of Medicine’s Committee on Quality of Health Care in America (2001) identified the imperative to focus on quality care and patient safety. The initiative to create cultures of patient safety and quality care remain at the forefront of the health care leadership landscape. Nursing leadership sub-competencies include the understanding of components and use of effective tools for successful quality improvement programs within the practice setting.Quality improvement and patient safety are central to the nursing leadership role. They are analyzed from many perspectives. Types of quality improvement and patient safety programs may range from internal, organization-based quality improvement team reports to external benchmarks from The Joint Commission, the Agency for Healthcare Research and Quality (AHRQ), Magnet, and numerous other organizations.

For a more recent snapshot of progress in the arena of patient safety, you may review a recent executive summary database report on safety cultures from the U.S. Department of Health & Human Services (n.d.). Lessons learned and tools presented within the directed readings provide a rich set of resources from which to draw for improved nurse leadership in the area of patient safety.

References

Institute of Medicine’s Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

U.S. Department of Health & Human Services. (n.d.). HHS.Gov. Retrieved from http://www.hhs.gov/

Write a 3–5 page safety score improvement plan for mitigating concerns, addressing a specific patient-safety goal that is relevant to quality patient care. Determine what a best evidence-based practice is and design a plan for resolving issues resulting from not maintaining patient safety.

Quality improvement and patient safety are health care industry imperatives (Institute of Medicine’s Committee on Quality of Health Care in America, 2001). Effective quality improvement results in system and organizational change. This ultimately contributes to the creation of a patient safety culture.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

  • Competency 1: Identify nursing leadership priorities using a systems perspective.
    • Identify a patient safety issue.
  • Competency 2: Apply systems theory and systems thinking to facilitate health care delivery and patient outcomes.
    • Apply systems thinking to explain how current policies and procedures may affect a safety issue.
    • Explain a strategy to collect information about the safety concern.
    • Explain a plan to implement a recommendation and monitor outcomes.
    • Recommend an evidence-based strategy to improve the safety issue.
  • Competency 4: Evaluate how power relates to health care organizational structure, behavior, and leadership.
    • Describe the influence of nursing leadership in driving the needed changes.
  • Competency 5: Communicate in a manner that is consistent with the expectations of a nursing professional.
    • Write content clearly and logically, with correct use of grammar, punctuation, and mechanics.
    • Correctly format citations and references using current APA style.
Reference

Institute of Medicine’s Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

Safety Score Improvement Plan Scoring Guide

CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED
Identify a patient safety issue. Does not identify a patient safety issue. Identifies patient safety concerns in general, but does not identify a specific issue. Identifies a patient safety issue. Identifies a patient safety issue and explains why the issue is a primary concern for nursing.
Describe the influence of nursing leadership in driving needed changes. Does not describe the influence of nursing leadership in driving the needed changes. Describes the influence of nursing leadership in general terms but does not describe how nursing leadership can drive change. Describes the influence of nursing leadership in driving the needed changes. Describes the influence of nursing leadership as a driving force for changes that affect patient safety and quality outcomes, and provides a specific example of driving a needed change.
Apply systems thinking to explain how current policies and procedures may affect a safety issue. Does not apply systems thinking to explain how current policies and procedures may affect a safety issue. Identifies leadership and structure responsible for current policies and procedures, but does not apply systems thinking to explain the connection to patient safety. Applies systems thinking to explain how current policies and procedures may affect a safety issue. Applies systems thinking to explain how current policies and procedures may affect a safety issue, and includes a discussion of how staff could monitor systems and implement safeguards.
Explain a strategy to collect information about the safety concern. Does not explain a strategy to collect information about the safety concern. Identifies several strategies to collect information about the safety concern, but does not explain one strategy. Explains a strategy to collect information about the safety concern. Explains a strategy to collect information about the safety concern and how it could be implemented, and identifies possible obstacles to obtaining information.
Recommend an evidence-based strategy to improve the safety issue. Does not recommend an evidence-based strategy to improve the safety issue. Describes strategies for improving a safety issue, but does not indicate if it is evidence based. Recommends an evidence-based strategy to improve the safety issue. Recommends an evidence-based strategy to improve the safety issue, and identifies potential limitations of the strategy.
Explain a plan to implement a recommendation and monitor outcomes. Does not explain a plan to implement a recommendation and monitor outcomes. Makes a recommendation, but does not explain how it will be implemented. Explains a plan to implement a recommendation and monitor outcomes. Explains a plan to implement a recommendation and monitor outcomes, and specifies quality indicators and accountable staff.
Write content clearly and logically, with correct use of grammar, punctuation, and mechanics. Does not write content clearly and logically, and there are errors in grammar, punctuation, and mechanics. Writes with errors in clarity, logic, grammar, punctuation, or mechanics. Writes content clearly and logically, with correct use of grammar, punctuation, and mechanics. Writes clearly and logically, with correct use spelling, grammar, punctuation, and mechanics, and uses relevant evidence to support a central idea.
Correctly format citations and references using current APA style. Does not correctly format citations and references using current APA style. Uses current APA to format citations and references but with numerous errors. Correctly formats citations and references using current APA style with a few errors. Correctly formats citations and references with no errors.

 

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Running head: SAFETY SCORE IMPROVEMENT PLAN Safety Score Improvement Plan for TrueWill General Hospital Learner’s Name Capella University Organizational and System Management for Quality Outcomes Safety Score Improvement Plan May, 2017 Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.Homework: safety score improvement plan.
1 SAFETY SCORE IMPROVEMENT PLAN 2 Safety Score Improvement Plan for TrueWill General Hospital Nursing professionals are key players in maintaining a culture of quality care and patient safety in a health care environment. Their role in addressing specific patient safety issues will be discussed using the example of TrueWill General Hospital (TGH), a 1,500-bed multispecialty hospital in the United States. The hospital regularly reports its performance data to the Hospital Safety Score, a nongovernmental organization that ranks hospitals on their safety rate. The safety score for the orthopedic inpatient unit of TGH has alarmingly increased because of the number of patient injuries resulting from falls. The negative score can affect the image of the hospital, because patient falls are preventable hospital-acquired conditions. The nurse manager of the unit has been advised by the hospital’s patient safety office to identify the cause of the problem, determine an evidence-based safety score improvement plan, and devise measurable long-term solutions for the safety issue. Factors behind the Patient Safety Issue Patient falls are one of the most reported patient safety incidents in health care practice. According to the American Nurses Association (n.d.), it is a serious problem in nursing and health care; as injuries resulting from falls can lead to permanent loss of function of certain body parts or even death. According to systems theory, adverse events such as patient falls are related to the quality of care provided by health care professionals at the front line of operations such as nursing professionals (Lawton, Carruthers, Gardner, Wright, & McEachan, 2012).Homework: safety score improvement plan.
Health care experts have relied on systems theory and systems thinking perspectives to analyze the incidence of safety issues as a nursing challenge. The theory states that problems in any part of a system, such as the nursing department in a hospital, will affect the functioning of Copyright ©2017 Capella University.
Copy and distribution of this document are prohibited. Comment [A1]: Yes, patient falls and how can lead to adverse effects, even death. SAFETY SCORE IMPROVEMENT PLAN 3 the hospital as a whole. Therefore, larger organizational systems should be taken into consideration while implementing changes in nursing profession to improve safety issues. Influence of Leadership in Changes for Safety Nurse leaders at TGH are an important systems factor in driving changes at the organizational and clinical level. The importance of leadership in achieving better patient outcomes or patient experiences was explored in a study of leadership practices and styles (Wong, Cummings, & Ducharme, 2013). The study showed that relational leadership styles, which focused on people and relations, improved patient outcomes because nurse leaders were able to assess patients’ needs better and coordinate staff and resources accordingly (Wong et al., 2013).Homework: safety score improvement plan.
TGH nurse leaders can use relational leadership styles to analyze the systems effect of safety issues on patients and nursing professionals. The leadership style can improve job satisfaction among nursing professionals by better managing staff and can enhance patient safety and satisfaction by providing quality care. Relational nurse leaders are also able to effectively use systems theory to analyze organizational policies and procedures that impact patients directly and affect the way nursing professionals deliver care. The Effects of Policies and Procedures on Safety Issues Policies and procedures govern every aspect of nursing such as management of staff, modes of health care delivery, and fiscal and material resources. When applied to policies and procedures governing staff management, systems theory helps nurse leaders assess the competencies of their nursing professionals, plan staff schedules to prevent work overload, hire more nurses to address shortages, and introduce strategies to retain current nurses. Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. Comment [A2]: Yes, patient centered care. SAFETY SCORE IMPROVEMENT PLAN 4 The dynamic systems model, a systems-theory-based model, can help nurse leaders monitor and reassess those policies (Morath, 2011). It promotes a transparent health care system where nurses are trained to (a) provide transparent care, (b) anticipate and pullback from risky Comment [A3]: The model promotes… practice, (c) work with other health care professionals, (d) monitor peers, and (e) be innovative and open to new technology that tests and studies safety practices. The model requires nurse leaders to research potential safety issues and gather evidence about those issues before implementing specific changes. Recommendations to Ensure Patient Safety Introducing changes for patient safety starts with collecting information, which will ensure an evidence-based approach to solving problems. The data collected will help devise a safety improvement plan. A structured approach to organizational change is important if the plan is to be properly implemented. The root cause analysis (RCA) is a systematic analysis of the common causes of safety issues. The RCA also devises strategies to prevent future safety incidents. Based on systems theory, the techniques of the RCA move beyond individual blame for clinical errors and examine the organizational factors that contribute to the errors (Huber, 2017; Dolansky & Moore, 2013).Homework: safety score improvement plan.
According to Dolansky and Moore, all nursing professionals must know how to conduct the RCA as it teaches them about systems theory. However, there are difficulties in obtaining Comment [A4]: Reference? information for the RCA. Teams that conduct RCAs often overlook important evidence in the care process in their hurry to complete the analysis before the stipulated 45 days set by the Joint Commission (Wocher, 2015). The lack of information can impede strategies for implementing evidence-based changes in safety. Evidence-based Strategy to Improve Patient Safety Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. Comment [A5]: Good inclusion of QSEN, to improve include limitations of the strategy. SAFETY SCORE IMPROVEMENT PLAN 5 Competency development integrated into staff management is a proven strategy in improving patient outcomes. One evidence-based education plan that can be adapted to clinical practice is the Quality and Safety Education in Nursing (QSEN) initiative. Funded by the Robert Wood Johnson Foundation, the competencies of the QSEN integrate quality improvement and safety management into nursing education (Dolansky & Moore, 2013). With the QSEN’s background in systems theory, nursing professionals can apply it at the individual and organizational levels of care. The six competencies of the QSEN are as follows: (a) patient-centered care, (b) evidence-based practice, (c) teamwork and collaboration, (d) safety, (e) quality improvement, and (f) informatics (Dolansky & Moore, 2013).Homework: safety score improvement plan.
Nursing professionals who develop these competencies are better able to deliver safe care and solve safety issues. However, there are limitations to the QSEN strategy. The QSEN is more than a decade old and has not been updated. Despite these difficulties, the QSEN competencies have become a key component of quality care and patient safety. Plan to Implement Safety Recommendation and Monitor Outcomes The education department teaches staff to think like systems thinkers and develop personal mastery over the profession and system (Burke & Hellwig, 2011). The education department at TGH could integrate QSEN competencies into education programs using a framework for organizational learning called the Baldrige framework. A system of continuous quality improvement, the Baldrige framework explains seven criteria that are indicators of quality for organizational learning programs: (a) leadership; (b) strategic planning; (c) focus on patients, other customers, and markets; (d) measurement, analysis, and knowledge management; (e) workforce focus; (f) process management; and (g) organizational performance results (Burke & Hellwig, 2011; Huber, 2017).Homework: safety score improvement plan.
Educational outcomes can be monitored at two levels: (a) the Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. Comment [A6]: Need to elaborate a little more about accountability of staff. SAFETY SCORE IMPROVEMENT PLAN 6 systems level where organizational performance is reviewed through patient and customer satisfaction surveys, scorecards, and human resources indicators; and (b) at the departmental level through pre- and post-testing of nursing professionals, course evaluations, further training of select nursing professionals, and assessments. The improvement of safety standards at TGH starts with developing the competency of its nurse leaders and nursing professionals. Because nursing professionals are at the front lines of care delivery, nurse educators should tailor programs, content, and goals to suit the unique needs of the nursing profession. Conclusion Patient safety issues such as patient falls are commonplace in a health care organization. Health care professionals must develop the foresight and strategic thinking to identify patient safety issues early and have solutions at the ready. The example of TGH shows the importance of preemptively addressing safety issues in nursing instead of letting them fester over time and affect organizational performance. TrueWill General Hospital and its leadership should take an active interest in developing nursing competencies continuously, focusing on quality and safety education. Embedding these ideas into the safety score improvement plan will create a lasting culture of quality care and patient safety. These are the standards that define the organization’s image in health care. Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. Comment [A7]: Good! SAFETY SCORE IMPROVEMENT PLANHomework: safety score improvement plan.
7 References American Nurses Association. (n.d.). Patient Falls. Retrieved from http://ana.nursingworld.org/qualitynetwork/patientfallsreduction.pdf Burke, K. M., & Hellwig, S. D. (2011). Education in high-performing hospitals: Using the Baldrige framework to demonstrate positive outcomes. The Journal of Continuing Education in Nursing, 42(7), 299–305. https://dx.doi/10.3928/00220124-20110103-01 Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education for nurses (QSEN): The key is systems thinking. OJIN: The Online Journal of Issues in Nursing, 18(3). Homework: safety score improvement plan.https://dx.doi/10.3912/OJIN.Vol18No03Man01 Huber, D. L. (2017). Leadership and nursing care management (6th ed.) Philadelphia: W.B. Saunders. http://dx.doi.org/10.7748/nm.21.6.13.s14 Lawton, R., Carruthers, S., Gardner, P., Wright, J., & McEachan, R. R. C. (2012). Identifying the latent failures underpinning medication administration errors: An exploratory study. Health Services Research, 47(4), 1437–1459. http://dx.doi.org/10.1111/j.14756773.2012.01390.x Morath, J. (2011). Nurses create a culture of patient safety: It takes more than projects. Online journal of issues in nursing, 16(3). Homework: safety score improvement plan.https://dx.doi/10.3912/OJIN.Vol16No03Man02 The Joint Commission. (2015). Root cause analysis in health care: Tools and techniques (5th ed.). Retrieved from http://jcrinc.com/assets/1/14/EBRCA15Sample.pdf Tomlinson, J. (2012). Exploration of transformational and distributed leadership. Nursing Management, 19(4), 30–34. http://dx.doi.org/10.7748/nm2012.07.19.4.30.c916 Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. SAFETY SCORE IMPROVEMENT PLAN 8 Wocher, J. C. (2015). The importance of a rigorous root cause analysis (RCA) for healthcare sentinel events. Japan-hospitals: The Journal of the Japan Hospital Association, 34, 23– 27. Retrieved fromHomework: safety score improvement plan. http://hospital.or.jp/e/pdf/13_20150700_01.pdf#page=26 Wong, C. A., Cummings, G. G., & Ducharme, L. (2013). The relationship between nursing leadership and patient outcomes: A systematic review update. Journal of nursing management, 21(5), 709–724. https://dx.doi/10.1111/jonm.12116 Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. …Homework: safety score improvement plan.