Description
Preparation
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.
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
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. 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.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.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/
-
Questions to Consider
To deepen your understanding, you are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of the health care community.Consider a performance measurement criteria or best practice guideline used in your work setting (or one that you are familiar with).
- How was this criterion or guideline implemented?
- Has it been successful?
- Is it used consistently?
- What evidence-based practices were used in developing the criteria or guideline?
- How was nursing involved in the criteria or guideline development?
- How was this criterion or guideline implemented?
-
Resources
- 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.
- Hospital Safety Score. (n.d.). What is patient safety? Retrieved from http://www.hospitalsafetyscore.org/what-is-patient…
- Agency for Healthcare Research and Quality. (n.d.). AHRQ. Retrieved from http://www.ahrq.gov
- National Academy of Medicine. (n.d.). Retrieved from http://nam.edu
- Centers for Medicare & Medicaid Services. (n.d.). Hospital-acquired conditions. Retrieved from https://www.cms.gov/medicare/medicare-fee-for-serv…
- American Nursing Informatics Association. (n.d.). ANIA. Retrieved from https://www.ania.org/
- HIMSS. (n.d.). Nursing informatics. Retrieved from http://www.himss.org/ASP/topics_nursingInformatics…
- Chao, S., Anderson, K., & Hernandez, l. (2009). Toward health equity and patient-centeredness: Integrating health literacy, disparities reduction, and quality improvement: Workshop Summary (2009). Washington, DC: The National Academies Press. Retrieved from http://www.nap.edu/catalog.php?record_id=12502
- The Joint Commission. (n.d.). National patient safety goals. Retrieved from http://www.jointcommission.org/standards_informati…
- AHRQ. (n.d.). Quality and patient safety. Retrieved from http://www.ahrq.gov/professionals/quality-patient-…
- AONE. (n.d.). Retrieved from http://www.aone.org/
- National Academies: Health and Medicine Division. http://www.nationalacademies.org/hmd/
- American Nurses Association. (n.d.). NursingWorld. Retrieved from http://nursingworld.org/
- American College of Healthcare Executives. (n.d.). Retrieved from http://www.ache.org/
- Institute for Healthcare Improvement. (n.d.). Retrieved from http://www.ihi.org/Pages/default.aspx
- U.S. Department of Health & Human Services. (n.d.). HHS.Gov. Retrieved from http://www.hhs.gov/
- National Institutes of Health. (n.d.) Retrieved from http://www.nih.gov/
- NCQA. (n.d.) Retrieved from http://www.ncqa.org/
- QSEN Institute. (n.d.). Retrieved from http://www.qsen.org/
- Agency for Healthcare Research and Quality. (2009). Hospital survey on safety culture: 2009 comparative database report. Retrieved from http://www.ahrq.gov/professionals/quality-patient-…
- Hospital Safety Score. (n.d.). Retrieved from http://www.hospitalsafetyscore.org/
I have provided the example given =)
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.
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).
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).
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).
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). 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). 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 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).
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). 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 from 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.
Purchase answer to see full
attachment
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.
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).
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).
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).
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). 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). 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 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).
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). 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 from 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.
Purchase answer to see full
attachment
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