Prepare an issue analysis of an incident that occurred in a health care organization and create a leadership action
plan (8-10 pages) that will help to address the specific incident but will also help to drive safety and quality
improvements throughout the organization.
In this third assessment in the course, you will assume the role of a newly promoted quality manager at your local
hospital. This role requires you to address deficiencies by improving organizational culture, providing leadership
oversight, and cultivating staff relationships within the organization. While you have many priorities in this new role,
one of your first is to analyze a recent incident that occurred within the organization and to create a leadership
action plan with recommended strategies and tactics to address not just the specific incident, but to drive safety and
quality improvement throughout the organization.
This assessment differs from the first assessment in that with this assessment, as the quality manager, your focus is
broader. Rather than focusing only on identifying specific actions the organization can take to remedy a
particular incident that occurred, you are concentrating on what steps you will take as the quality manager to
influence the organization’s leadership to cultivate a fair and just culture. You will determine what departments, what
leaders, and what personnel you will collaborate with to improve quality for the whole organization. In this type of
culture, safety is at the forefront of everyone’s job and all associates welcome the opportunity to highlight issues—
without fear of reprisal—so that they can be addressed at a systemic level throughout the organization.
You may find it useful to review the short document CQI Importance and Features [PDF] as you gather your thoughts
about the key elements you want to include in your assessment, Issue Analysis and Leadership Action Plan.
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.
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7/12/22, 6:54 PM Assessment 3 Instructions: Collaborate on Quality: Issue …
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Preparation
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.)
Instructions
Write an analysis and leadership action plan for the issue you selected that will enable you to address the issue on an
organization-wide basis. Please make sure to include all of the following headings and answer all of the questions
underneath each heading.
Issue Summary
How would you summarize the key elements of the incident that occurred?
What is your goal in addressing the issue?
Which two to three key items will be your focus? For example, you may elect to focus on nursing staffing
levels if being short staffed in nursing is contributing to compromises to patient safety.
IHI Triple Aim
What is the IHI Triple AIM?
How does the IHI Triple Aim apply to this specific incident?
What IHI Triple Aim elements will you incorporate into your organizational improvement strategy?
Culture
What is culture?
Why is culture a critical organizational priority for safety and quality?
Based on the knowledge you have about the selected issue, what do you know about the existing
organizational culture?
What are some of the evidence-based strategies you are considering you could employ to cultivate a culture
of safety?
Collaboration
Which key departments need to be directly involved with the corrective action process?
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What is your rationale for selecting these departments? For example, you may want to involve nursing
because many of errors involve nurses and obtaining their buy-in is critical to achieving the organizational
priority.
Which specific senior leader, front line staff member, and clinical expert will you include in your action plan
and hold accountable for implementation?
What are the implications of not engaging with all departments toward making safety and quality top of
mind?
How might you involve other departments in addressing the specific issue and the cultural issue?
Leadership
Which specific leaders within the organization could assist you in addressing this issue and in making patient
safety and quality top of mind throughout the organization? Examples for you to consider include the chief
nursing officer, the chief medical officer, the patient safety officer, et cetera.
What role do you expect these leaders to play in addressing the specific issue and the issue of culture?
What best practices would you employ to enlist their aid in the improvement effort?
What role does the organization’s governing board have in terms of quality and safety in the organization?
How could you enlist the governing board’s aid in your improvement initiative?
What additional information could you provide them to increase their involvement in the organization’s safety
and quality improvement efforts?
Leadership Action Plan
What are three evidence-based actions you recommend that would help to solve the incident that arose?
What are three evidence-based best practices you recommend to address the issue on an organizational
level?
Conclusion
How will you summarize your analysis of the incident and your leadership action plan?
Remember that health care is an evidence-based field. You will need to cite a minimum of two credible references to
support your analysis and action planning process.
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.
Additional Requirements
Length: Your incident analysis and leadership action plan will be 8–10 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.