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Importance and Features of Continuous Quality Improvement (CQI) Depending on the organization, continuous quality improvement (CQI) programs differ in size and scope. Likewise, they may be called a variety of names, such as quality and performance improvement, quality management, regulatory compliance, and quality improvement (Sollecito & Johnson, 2013). Despite the progress in CQI, health care quality improvement requires greater continued efforts due to the health care environment’s vibrant and complex nature.
CQI is a “structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations” (Sollecito & Johnson, 2013, p. 4). A common set of features characterizes CQI, which includes the following (Sollecito & Johnson, 2013, pp. 4–5):
• A link to key elements of the organization’s strategic plan. • A quality council made up of the institution’s top leadership. • Training programs for personnel. • Mechanisms for selecting improvement opportunities. • Formation of process improvement teams. • Staff support for process analysis and redesign. • Personnel policies that motivate and support staff participation in process
improvement. • Application of the most current and rigorous techniques of the scientific method
and statistical process control.
For CQI to flourish within an organization, it needs to be rooted in the organization’s culture. Culture is the combination of shared attitudes, values, competencies, goals and behaviors that define the organization’s practices (Silva, Barbosa, Padilha, & Malik, 2016). All stakeholders within the organization are responsible for health care quality and safety.
Leaders who wish to create a safety culture must first assess their organization’s readiness to implement the necessary safety practices. In addition, the Agency for Healthcare Research and Quality (AHRQ) has created culture assessment tools that allow organizations to identify benchmarks to establish a culture of safety in comparison to similar hospitals or hospital units. The fair and just culture concept encourages leaders to ask what happened instead of who made the error (Pelletier & Beaudin, 2018). Additionally, a fair and just culture aids in making the system safer. Stakeholders understand errors are inevitable and that all errors need to be reported, even when events may not cause patient harm (Pelletier & Beaudin, 2018).
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Pelletier and Beaudin emphasize how critical it is for leaders to assume responsibility for driving improved patient safety practices throughout the organization (2018). To demonstrate this, leaders need to incorporate health care safety practices as a part of the organization’s strategic direction and to develop goals to guarantee adoption and measurement of safe practices. The governing body or board of directors is responsible for endorsing and upholding quality of care and preserving safety. Quality oversight is recognized more clearly as a core fiduciary duty relating not only to financial health and reputation but to safety and quality of care (Pelletier & Beaudin, 2018).
References
Pelletier, L. R., & Beaudin, C. L. (2018) HQ solutions: Resource for the healthcare quality professional (4th ed.). Philadelphia, PA: Wolters Kluwer.
Silva, Natasha Dejigov Monteiro da, Barbosa, A. P., Padilha, K. G., & Malik, A. M. (2016). Patient safety in organizational culture as perceived by leaderships of hospital institutions with different types of administration. Revista Da Escola De Enfermagem Da U S P, 50(3), 490-497.
Sollecito, W. A., & Johnson, J. K. (2013). Mclaughlin and Kaluzny’s continuous quality improvement in health care (4th ed.). Burlington, MA: Jones & Bartlett Learning.
- Importance and Features of Continuous Quality Improvement (CQI)
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Collaborate on Quality: Issue Analysis & Leadership Action Plan
Your Name
Date:
Collaborate on Quality: Issue Analysis & Leadership Action Plan
[Provide a brief introduction to this paper. Delete all statements within brackets, such as this paragraph, and replace with your discussion. Also, before you begin, review the “Scoring Guide” and understand the difference between “Distinguished”, “Proficient”, “Basic” and “Non-Performance”. These “Scoring Guides” are used to grade the assignment. This is why each Template is set up with headings (below) that correspond with the “Scoring Guides” for this specific assignment. Please leave the Headings (below) in the paper.]
Culture
[Explain what culture is and why it is a critical priority for safety and quality; what you know about the existing organizational culture, based on the knowledge you have about the selected issue; providing at least two evidence-based strategies for cultivating a culture of safety.]
IHI Triple Aim
[Apply the IHI Triple Aim to develop a health care leadership strategy that focuses on optimizing health care system performance. Include: 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?]
Leadership & Collaboration Strategies
[Propose evidence-based (requires sources that support the strategies) leadership and collaboration strategies to enlist the aid of key organizational leaders in establishing a safety and quality culture. Include: 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?]
Leadership Action Plan
[Propose an evidence-based (requires sources that support the strategies) leadership action plan that includes leadership strategies to establish a safety and quality culture. What are three evidence-based leadership strategies your recommend that would help to solve the incident that occurred? What are three evidence-based best practices you recommend to address the issue on an organizational level?]
Opportunities to Enlist Governing Board
[Determine opportunities to enlist the governing board’s aid in fostering a fair and just culture. Include: 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?]
Conclusion
[Provide a summary of your discussion.]
References
[Lastname, C. (2008). Title of the source without caps except Proper Nouns or: First word after colon. The Journal or Publication Italicized and Capped, Vol# (Issue#), Page numbers.
Lastname, O. (2010). Online journal using DOI or digital object identifier. Main Online Journal Name, Vol#(Issue#), 159-192. doi: 10.1000/182
Lastname, W. (2009). If there is no DOI use the URL of the main website referenced. Article Without DOI Reference, Vol#(Issue#), 166-212. Retrieved from http://www.mainwebsite.org
NOTE: The above references are SAMPLES ONLY. For more information and example related to references, visit Capella’s Writing Center. YOU ARE RESPONSIBLE FOR SUBMITTING APPROPRIATE IN-TEXT AND REFERENCE PAGE CITATIONS.]
Assessment 3
Issue Analysis and Leadership Action Plan
prepare an issue analysis of an incident that occurred in a health care organization and create a leadership action plan that will help to address the specific incident but will also help to drive safety and quality improvements throughout the organization. The issue analysis and action plan together should be 8 pages.
Introduction
The quality manager at any hospital is required to address deficiencies by improving organizational culture, providing leadership oversight, and cultivating staff relationships within the organization. This role has many priorities. For example, a quality manager is tasked with analyzing any incidents that occur within the organization and creating 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.
The following assessment differs from the first two assessments in that, acting 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. What departments, leaders, and personnel will you 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.
Preparation
To successfully complete this assessment, use the Collaborate on Quality Template [DOC] to address the following:
· Select one of the three incidents from the Vila Health: Patient Safety simulation. These are common incidents you are likely to encounter in the health care field. You may select one of the incidents you worked with in the previous assessments or select a different one. Choose the one that holds the most interest to you. These incidents included:
· A patient identification error.
· A medication error.
· A HIPAA/privacy violation.
· Consider the following 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, or 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 lapse in best practices may have contributed to the issue? ( Note: This information will prove useful to you as you complete your analysis and leadership action plan.)
· Review the Collaborate on Quality Template [DOC] , which you will use to complete this assessment. This document is formatted and has space for completing all components of the assessment.
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.
· Introduction: Issue Summary.
· How would you summarize the key elements of the incident that occurred?
· What is your goal in addressing the issue?
· Which 2–3 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.
· Culture: Explain what culture is and why it is a critical priority for safety and quality, providing at least two evidence-based strategies for cultivating a culture of safety.
· What is culture?
· Why is culture a critical organizational priority for safety and quality?
· What do you know about the existing organizational culture, based on the knowledge you have about the selected issue?
· What are some of the evidence-based strategies you are considering that could be employed to cultivate a culture of safety?
· IHI Triple Aim: Apply the IHI Triple Aim to develop a health care leadership strategy that focuses on optimizing health care system performance.
· 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?
· Leadership and Collaboration: Propose evidence-based leadership and collaboration strategies to enlist the aid of key organizational leaders in establishing a culture of safety and quality.
· 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 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?
· Leadership Action Plan: Create an evidence-based action plan that includes leadership strategies to establish a culture of safety and quality.
· What are three evidence-based—meaning supported by current literature—leadership strategies you recommend that would help to solve the incident that occurred?
· What are three evidence-based best practices you recommend to address the issue on an organizational level?
· Opportunities to Enlist Governing Board: Determine opportunities to enlist the governing board’s aid in fostering a fair and just culture.
· 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?
· Conclusion.
· How will you summarize your analysis of the incident and your leadership action plan?
In addition, your assessment needs to conform to current APA style and format guidelines. Ensure that it is clear, persuasive, concise, organized, and without errors in grammar, punctuation, and spelling. Provide citations and title and reference pages in current 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.
Note: 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.
Please review the Collaborating on Quality: Issue Analysis and Leadership Action Plan Scoring Guide to ensure you understand the grading requirements for this assessment.
Additional Requirements
Your assessment should also meet the following requirements:
· Template: Use the Collaborate on Quality Template [DOC] to complete this assessment.
· Length: 8–10 double-spaced pages, excluding title and reference pages.
· Font and font size: Times New Roman, 12 point.
· APA format: Your submission—including the body, citations, and title and reference pages—needs to be in APA format and style guidelines. It needs to be well-written, include the headings specified in the instructions, and address the questions listed under each heading.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
· Competency 4: Apply leadership strategies to quality improvement in a health care organization.
· Explain what culture is and why it is a critical priority for safety and quality, providing at least two evidence-based strategies for cultivating a culture of safety.
· Apply the IHI Triple Aim to develop a health care leadership strategy that focuses on optimizing health care system performance.
· Propose evidence-based leadership and collaboration strategies to enlist the aid of key organizational leaders in establishing a safety and quality culture.
· Create an evidence-based action plan that includes leadership strategies to establish 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 the expectations for health care professionals.
· Use correct grammar, punctuation, and mechanics as expected of an undergraduate learner.
· Writing adheres to APA formatting rules and APA writing style with few or minor errors.