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 issueswithout fear of reprisalso 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.
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
- Competency 4: Apply leadership strategies to quality improvement in a health care organization.
- Apply the IHI Triple Aim to develop a health care leadership strategy that focuses on optimizing health care system performance.
- Propose evidence-based leadership strategies that will help to establish a safety and quality culture.
- Propose evidence-based leadership and collaboration strategies to enlist the aid of key organizational leaders in establishing a safety and quality culture.
- Determine opportunities to enlist the governing board’s aid in fostering a fair and just culture.
- Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals.
- Write a clear, organized, persuasive, and generally error-free issue analysis and leadership action plan that promotes a culture of safety and quality and is reflective of professional communication in the health care field.
- Provide citations and title and reference pages that conform to APA style and format.
To help prepare for successfully completing this assessment:
- Select one of the three incidents from the Vila Health: Patient Safety simulation you completed in Assessment 1. 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 assessments or select another one. Pick one that holds the most interest for you.
- Consider these 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, 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.)
- 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:
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.
- 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?
- 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?
- 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?
- 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?
- 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, in the health care field, your analysis and action plan would not typically be written in APA format. 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 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.
- Length: Your incident analysis and leadership action plan will be 810 double-spaced pages, not including title and reference pages.
- Font: Times New Roman, 12-point.
- APA Format: Your citations and title and reference pages need to be in APA format. The body of your analysis does not need to be written in APA format. It does need to be well written, include the headings specified in the instructions, and address the questions listed under each heading.
- Scoring Guide: Please review this assessment’s scoring guide to ensure you understand how your faculty member will evaluate your work.Vila Health: Patient Safety
- Scene 1
- Patient Identification
- Scene 2
- Medication Error
- Scene 3
Independence Medical Center is a rural referral hospital with 115 beds in Independence, Iowa. Like all hospitals, administrators and providers try to avoid errors, and its the patient safety officers role to monitor the hospitals safety posture and recommend better practices. But what happens when a mistake leads to a medication error?Patient Identification
At Independence Medical Center, the patient safety officer conducts daily safety rounds. Today, shes rounding at the pediatric unit on the eighth floor.Kyra Dilley and Virginia Anderson
Kyra Dilley: Hi, wheres the charge nurse?Virginia Anderson: Thats me. Whats up?Kyra Dilley: Well, Im doing my safety rounds and I noticed that there are two patients on this floor in rooms directly across from each other: B. Moore and B.R. Moore.Virginia Anderson: Thats not all they have really similar birthdates! B. Moore was born on 8/11/05 and B. R. on 11/8/05.Kyra Dilley: Okay, thats even more concerning. How are you making sure not to confuse those patients?Virginia Anderson: Its not a problem. Were making sure that the two patients always have different nurses.Kyra Dilley: Well, thats good, but I have to warn you that this is a troubling situation. Are all shifts aware of the need to schedule nurses around this?Virginia Anderson: There are notes in both charts. We had to do that; weve been short staffed this week and theres been a lot of shifting around.Now that you’ve spoken with some clinical stakeholders, answer the following questions:
Question 1: If the PSO determines this is a trending issue on this unit, which step should she include in the corrective action?Your response:Incorrect.
Correct Answer: In-service education for the entire unit on which the errors continue to trend.Education for the entire facility is not warranted at this time, given that the error is trending only on one specific unit.Incorrect.
Correct Answer: In-service education for the entire unit on which the errors continue to trend.Using only one identifier does not meet regulatory standards.Correct Answer: In-service education for the entire unit on which the errors continue to trend.Given that the errors are trending on the unit, all staff on the unit should attend in-service education on this issue.Correct!
Providing in-service education to the entire staff on the unit on which the error is trending is important. While only two nurses were involved in this error, the next error could occur with different staff. In addition, re-educating the entire unit is beneficial, as fellow staff members often catch errors that others do not see.Question 2: Which operational consideration is NOT a priority in terms of reducing patient identification errors?Your response:Incorrect.
Correct Answer: Reason for admission to the unit.The room assignment process is an important item to consider, as no process may be in place to strategically put patients on the unit when an error may occur due to identification or other similar factor. The PSO may want to revise the current process or create one if one doesnt exist. This is a potential re-education topic if a room assignment process does exist but staff members do not adhere to it, or if the process is revised and staff members require education about the revised process.Incorrect.
Correct Answer: Reason for admission to the unit.Reviewing the process for alerting staff members of potential safety errors due to patient identification is important to consider. The patient safety officer may want to revise the current process or create one if one doesnt exist. This is a potential re-education topic within the organization if a process for alerting staff members of potential safety errors due to patient identification exists but staff members do not adhere to it, or if the process is revised and staff members require education about it.Incorrect.
Correct Answer: Reason for admission to the unit.Reviewing the floor census is an important consideration in this case. The patient safety officer will want to determine working conditions at the time the error occurred. For example, was the unit short-staffed at the time of the error? Was there an emergency in the unit at the time the error occurred, distracting staff members?Correct!
At this time, knowing the reason for admission to the unit is not a priority, because the issue involves patient identification. Diagnosis is not an element used in patient identification.Question 3: What potential next steps might a patient safety officer take?Your response:Expert Response: Health care experts in patient safety and quality improvement identified the following as important next steps when a patient identification issue arises:
- Review any existing room assignment policies and procedures.
- Interview staff members assigned to each patient to determine their process for proper patient identification to ensure mix-ups are avoided.
- Notify the risk manager of the potential patient safety error.
- Educate the family about the importance of active involvement in their childs care and about the organizations patient identification process.
- Question 4:
True or false: Regulatory agencies require the use of three patient identifiers (such as name, DOB, or address) to identify patients.Your response:Incorrect.
Correct Answer: False.The Joint Commission requires health care organizations to use two patient identifiers.Correct!
The Joint Commission requires health care organizations to use two patient identifiers, not three.Question 5: What are the potential implications for a health care organization if a mistake or an adverse event occurs as the result of a patient identification error?Your response:Expert Response: Health care experts in patient safety and quality improvement cited the following as potential implications for the organization if a mistake or adverse event occurs as the result of a patient identification error:
- Continued medication, blood transfusion, and procedural errors.
- Increased costs to the organization.
- Adverse effects on patient health.
- Increased regulatory oversight, which could lead to fines, penalties, or loss of accreditation.
- Question 6: What are the potential implications for the patient if a mistake or an adverse event occurs as the result of a patient identification error?Your response:Expert Response: Health care experts in patient safety and quality improvement cited the following as potential implications for the patient if a mistake or an adverse event occurs as the result of a patient identification error:
- Prolonged admission, resulting in increased costs and diminished patient satisfaction.
- Disability or death.
- Loss of trust in the health care organization.
- Medication Error
Later that week, the PSO gets a call from the hospitals risk manager.Kyra Dilley and Arthur Chester
Kyra Dilley: This is Kyra Dilley.Arthur Chester: Hi, Kyra, this is Arthur Chester. Im calling to let you know about a medication error on the eighth floor.Kyra Dilley: Oh, no. Was it B. Moore or B.R. Moore?Arthur Chester: How did you know? It was B. Moore, birthdate 8/11/05. My investigation isnt complete but there were two patients with similar names and birthdates in rooms in close proximity.Kyra Dilley: Okay. Have you interviewed the nurses involved yet? There should have been different nurses for each patient.Now that you’ve spoken with some non-clinical stakeholders, answer the following questions:
Question 1: Given the information about the medication error, which is the most appropriate first step for the patient safety officer to take?Your response:Incorrect.
Correct Answer: Check on the patients clinical status.Determining whether the medication error is an isolated event or a trending issue is an important step, but it can be performed later during the investigation.Incorrect.
Correct Answer: Check on the patients clinical status.Notifying the risk manager is an important step, but it is not the first step.Correct!
Patient safety always comes first. It is the patient safety officers first responsibility to check on and document the patients clinical status.Incorrect.
Correct Answer: Check on the patients clinical status.Health care organizations are not required to report all errors to the regulatory agency. Additional fact finding and possibly a complete investigation need to be performed before notifying the regulatory agency.Question 2: Which of the following has the least impact on the medication error?Your response:Incorrect.
Correct Answer: Scheduling of the unit secretary.The original medication order is important to consider when investigating the error. The original order may have been transcribed incorrectly, or it may contain important information related to why the error may have occurred. For example, the original order may have been illegible, it may have requested an incorrect dose, or it may contain a look-alike or sound-alike medication.Incorrect.
Correct Answer: Scheduling of the unit secretary.Knowing which medication was administered is important to consider, because this may have a significant impact on the patients prognosis.Incorrect.
Correct Answer: Scheduling of the unit secretary.Staff workload and working conditions at the time of the error are important considerations in this situation. The staff may have been overwhelmed, distracted, or focused on other items, resulting in a lack of focus on this particular patient.Correct!
Whether this unit had a secretary scheduled to work at the time of the error is unlikely to have had an impact on the medication error.Question 3: The Joint Commission states all of the following about medication errors or issues EXCEPT:Your response:Correct!
The Joint Commission states that medication errors often result in adverse events.Incorrect.
Correct Answer: Although common, medication errors do not often result in adverse events.The Joint Commission requires health care organizations to conduct a root cause analysis to determine the cause of the medication error.Incorrect.
Correct Answer: Although common, medication errors do not often result in adverse events.The Joint Commission requires health care organizations to develop a corrective action plan and monitor it closely to ensure its effectiveness.Incorrect.
Correct Answer: Although common, medication errors do not often result in adverse events.The Joint Commission encourages patients and caregivers to actively participate in their health care.Question 4: From a regulatory perspective, the best resource to consult on medication errors is:Your response:Incorrect.
Correct Answer: The appropriate regulatory agencys accreditation manual.The previous patient safety officer is not the best choice, as this individual may no longer be with the organization. Likewise, regulatory agency standards change frequently, and the previous patient safety officers knowledge of regulatory agency standards may be outdated.Incorrect.
Correct Answer: The appropriate regulatory agencys accreditation manual.Previous actions the organization took in similar cases is not the best resource to consult in the case of medication errors. Each case needs to be considered as a separate event, for the conditions and specifics of each event differ, and previous actions may not apply. In addition, the organization may not have taken the best or most appropriate action on previous similar cases.Incorrect.
Correct Answer: The appropriate regulatory agencys accreditation manual.The health care organizations legal team is not the best resource to consult in the event of a medication error. The health care organizations legal team represents the health care organization, not the regulatory agency.Correct!
From a regulatory perspective, the appropriate agencys accreditation manual is the best resource to consult in the event of medication errors. This manual will provide the most current, applicable, and accurate information.Question 5: What is a medication error called when it is corrected before it occurs?Your response:Correct Response: These are called near misses.Question 6: What is a medication error called when it is corrected before it occurs but could have resulted in a patients death?Your response:Correct Response: These are called adverse events.Question 7: What is a medication error called when it results in the patients death?Your response:Correct Response: These are called never or sentinelevents.Question 8: Which of the following would be a potential consequence for the health care organization if a medication error resulted in the patient having a prolonged hospital stay?Your response:Incorrect.
Correct Answer: Increased cost to the health care organization.Patient disability would be a consequence for the patient rather than for the health care organization. However, a patient disability could be a consequence for the organization if the patient chose to pursue legal action against the organization.Correct!
An increased length of stay will result in increased costs to the organization, because it will have to care for the patient for a longer period of time than would have been necessary absent the medication error.Incorrect.
Correct Answer: Increased cost to the health care organization.An increased length of stay does not necessarily mean that a sentinel or adverse event will occur.Incorrect.
Correct Answer: Increased cost to the health care organization.An increased length of stay for a patient due to a medication error would not necessarily result in a loss of accreditation.Question 9: The two most common methods health care organizations use to encourage event reporting include: ___________ and ____________.Your response:Correct Responses: Health care experts in patient safety and quality improvement cited the following as potential implications for the organization if a mistake or adverse event occurs as the result of a patient identification error:
- Incident reporting
- For additional information about health care organizations handling of medication errors, consult these internet resources:
Agency for Healthcare Research and Quality. (2005). Getting to the root of the matter.
Agency for Healthcare Research and Quality. (2017). Medication errors.HIPAA
The day after the medication error, B. Moores mother signs in at the front desk to get her visitation pass. As she is standing at the front desk, she overhears an inappropriate conversation between Ida Feeney, the unit secretary, and a nurse from a different unit of the hospital.Ida Feeney and Brenda Turner
Ida Feeney: Did you hear about the Moore kid? Its a good thing they caught that right away. Shes small for her age, and that insulin could have really done a number on her.Brenda Turner: Jeez, how much did they give her?Ida Feeney: Well, she wasnt supposed to have any. But I forget the actual dose. Ill look in the EHR later, but I think it was pretty high.Brenda Turner: Wait, is it Belinda Moore?Ida Feeney: Yes, why?Brenda Turner: I think shes in a gymnastics class with my daughters!Now that you have observed this inappropriate conversation, answer the following questions about HIPAA regulations.
Question 1: Which regulatory agency is responsible for overseeing the HIPAA privacy and security rule?Your response:Incorrect.
Correct Answer: U.S Department of Health and Human Services.The Joint Commission is an independent regulatory agency. It is not part of the U.S. government, and it does not have the authority or responsibility to enforce privacy and security rules.Incorrect.
Correct Answer: U.S Department of Health and Human Services.While the DEA is a U.S. government regulatory agency, its purpose is not to oversee the HIPAA privacy and security rules. Its primary responsibility is to enforce controlled substances laws.Correct!
The U.S Department of Health and Human Services Office of Civil Rights is responsible for enforcing the HIPAA privacy and security rules.Incorrect.
Correct Answer: U.S Department of Health and Human Services.While CLIA is a U.S. government regulatory body, its purpose is not to enforce the HIPAA privacy and security rules. CLIAs purpose is to ensure laboratory testing quality.Question 2: How would the health care organizations privacy officer determine whether others who were not involved in the patients care had viewed her medical record?Your response:Expert Response: Health care experts on the HIPAA privacy and security rules indicate the best way to determine whether a patients medical record was accessed inappropriately is to conduct file audits. These audits may include, but are not limited to:
- Random file reviews to determine who has recently accessed a patients medical record and if this access was warranted.
- Reviews of business associate contracts.
- Audits of disclosures in accordance with the privacy notice, along with the organizations adherence to confidential communications protocols.
- Question 3: Health care experts on the HIPAA privacy and security rules indicate the following as the most appropriate sequence to follow in addressing the potential HIPAA violation.
- Meet with B. Moores mother to document the details of her complaint.
- Inform risk manager of the potential violation.
- Audit B. Moores medical record to determine who has accessed it during her stay.
- Interview involved employees.
- Determine whether any discipline is warranted.
- Educate staff about the HIPAA rule.
- Your response:Correct!
Investigations collect as much information as possible. Information and data collected in the investigation will help the privacy officer to determine whether an actual breach occurred, ensure that all aspects of the complaint have been examined, and minimize risks to the organization and the patient.Incorrect.
Correct Answer: TrueInvestigations collect as much information as possible. Information and data collected in the investigation will help the privacy officer to determine whether an actual breach occurred, ensure that all aspects of the complaint have been examined, and minimize risks to the organization and the patient.Question 4: Identify the most common penalties employees may face if they are found in violation of HIPAA.Your response:Expert Response: Health care experts on the HIPAA privacy and security rules indicate that failure to comply with HIPAA may result in civil and criminal penalties. Violations of the law include those that are unknowing, reasonable cause, or willful neglect both corrected and uncorrected. The most common penalties employees face when they are found to have violated HIPAA rules include:
- Monetary penalties ranging from $100 to $1.5 million.
- Prison sentences up to 10 years.
- Disciplinary action, up to and including termination.
- Question 5: How would a privacy officer determine whether this is an isolated event or a trending issue? Why is this an important part of the investigation?Your response:Expert Response: Health care experts on the HIPAA privacy and security rules recommended these best practices to determine whether potential HIPAA violations are isolated events or trending issues:
- Conduct random audits to determine whether this employee or others have been accessing the medical records of patients who are not under their care.
- Perform reviews of patient and family complaints.
- Determining whether HIPAA violations are isolated events or trending issues is an important part of this investigation, because this information will reveal whether the