Leadership in Healthcare Organization

Write a 5-7 page recommendation to senior leadership about steps the organization needs to take to resolve a patient safety issue.
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Introduction
Alarming numbers of unnecessary patient deaths occur in U.S. hospitals and around the world. “Quality and patient safety in health care have been on the forefront of the public’s mind since the publication of the Institute of Medicine’s (IOM) seminal report, ‘To Err Is Human,’ in 1999” (Johnson, Haskell, & Barach, 2016, p. xv). The literature supports revising systems and processes in an effort to narrow the difficult safety and quality gaps. Worldwide, issues of patient safety and patient-centered quality care drive health care reform. Current approaches are not adequate; patients remain at risk for needless harm.
Demonstrating a firm understanding of the various components of patient safety is fundamental to understanding health care quality, risk management, and patient safety overall.
Reference
Johnson, J. K., Haskell, H. W., & Barach, P. R. (2016). Case studies in patient safety. Jones & Bartlett Learning.
Preparation
To successfully complete this assessment:
• Review the following three scenarios from the Vila Health: Patient Safety simulation activity. Choose the scenario that interests you the most for further analysis in your assessment:
o Scenario 1: Patient Identification Error.
o Scenario 2: Medication Error.
o Scenario 3: HIPAA/Privacy Violation
Medication error is selected. Simulation conversation below
Kyra Dilley: This is Kyra Dilley.
Arthur Chester: Hi, Kyra, this is Arthur Chester. I’m 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 isn’t 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.

• Review the Address a Patient Safety Issue 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
For the scenario you selected, use the Address a Patient Safety Issue Template [DOC] to write a five-to-seven page recommendation for leadership that describes the safety threat, the importance of addressing the threat, and your recommendations for resolving it. Be sure to include all of the following in your paper and to address all of the points:
• Apply the health care safety imperative to a patient safety issue.
o Identify the issue you selected from the Vila Health simulation as the potential safety threat.
o Describe the issue that occurred with sufficient detail so that leadership has a clear understanding of what happened.
o Identify the implications of not addressing the threat.
• Evaluate the risk to the patients, employees, and organization if patient safety threats are not addressed.
o What does the health care safety imperative say about the issue?
o How does the health care safety imperative apply in this case?
o Which regulatory agencies have oversight about the issue?
• Analyze regulatory agencies’ role and impact on organizations’ patient safety programs.
o What specifically do the regulations state about the issue? For example, you might consider the Joint Commission’s NPSGs.
o What impact do regulatory agencies have on organizations’ patient safety programs?
o How do health care organizations incorporate regulatory agencies’ guidance when establishing reporting and investigation best practices?
o What are the potential consequences to the patients, employees, and organization if the hospital fails to correct the threat?
• Analyze the patient safety officer’s role in implementing patient safety plans.
o Explain the role patient safety officers assume in implementing patient safety plans in health care organizations.
o Clarify your responsibility and role as the patient safety officer in this specific instance.
o Provide one example from the literature to illustrate your points.
• Recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.
o Describe your five-point plan to reduce or eliminate this patient safety threat.
 What best practice tools or techniques do your plan include to reduce or eliminate these types of errors? Consider processes for responding, rounding, detecting, incident reporting, operational considerations, et cetera.
In a health care professional setting, recommendations to leadership would typically not be in APA format. However, your paper does need to conform to the current APA format and style guidelines. It does need to be clear, persuasive, organized, and well written without spelling, grammar, and/or punctuation errors. In addition, recommendations you write in a professional setting would be single-spaced. For the purpose of this assessment, however, please use double-spacing. See the APA Module for more information about APA style.
Also, health care is an evidence-based field. Your senior leaders will want to know the sources of your information, so be sure to include at least two peer-reviewed sources. You may use the suggested resources for this assessment. Your citations and references need to conform to APA guidelines.
Please review the Addressing a Patient Safety Issue Scoring Guide to ensure you understand the grading requirements for this assessment.
Additional Requirements
• Template: Use the Address a Patient Safety Issue Template [DOC] to complete this assessment.
• Length: 5–7 double-spaced pages, excluding title and reference pages.
• Font: Times New Roman, 12-point.
• APA Format: Your submission— including the body, citations, and title and references pages— needs to conform to current APA format and style guidelines. Make sure that it is clear, persuasive, organized, and well-written, without grammatical, punctuation, or spelling errors. Also, you must cite your sources according to current APA guidelines.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
• Competency 1: Analyze the quality and performance improvement activities within the health care organization.
o Recommend evidence-based best practice tools and techniques to reduce or eliminate patient safety threats.
• Competency 3: Analyze the importance of patient safety in health care.
o Apply the health care safety imperative to a patient safety issue.
o Evaluate the risk to patients, employees, and the organization if patient safety threats are not addressed.
o Analyze regulatory agencies’ role and impact on organizations’ patient safety programs.
• Competency 4: Apply leadership strategies to quality improvement in a health care organization.
o Analyze the patient safety officer’s role in implementing patient safety plans.
• 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.
o Use correct grammar, punctuation, and mechanics as expected of an undergraduate learner.
o Writing adheres to APA formatting rules and APA writing style with few or minor errors.
Resources
Use the resources linked below to help complete this assessment.
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History and Overview
These readings provide a historical background to patient safety and health care quality.
• Use the Patient Safety Handbook to read the following:
o Chapter 2, “Patient Safety Movement: The Progress and the Work That Remains,” pages 17–28.
• Use The Healthcare Quality Book to read the following:
o Chapter 1, “Overview of Healthcare Quality,” pages 5–32.
The Safety Imperative
• Allen, G. (2015). Infection prevention: A patient safety imperative for the perioperative setting. AORN Journal, 101(5), 508–510.
• Patient Safety Movement. (n.d.). https://patientsafetymovement.org/
• Patient Safety Movement. (n.d.). Emily Jerry [Video] | Transcript https://patientsafetymovement.org/advocacy/patients-and-families/patient-stories/emily-jerry/
Regulatory Agencies
• Joint Commission. (2021). National patient safety goals. https://www.jointcommission.org/standards/national-patient-safety-goals/
• Joint Commission. (n.d.). Sentinel event. https://www.jointcommission.org/sentinel_event.aspx
• Agency for Healthcare Research and Quality. (2017). About the National Quality Strategy. http://www.ahrq.gov/workingforquality/about/index.html
Familiarize yourself with the following sites for information about some additional accreditation bodies:
• Det Norske Veritas, Inc. (n.d.). Healthcare assurance services by DNV. https://www.dnv.com/healthcare/index.html
• Accreditation Association for Ambulatory Health Care. (n.d.). https://www.aaahc.org/
• Centers for Medicare & Medicaid Services. (n.d.). https://www.cms.gov/
Regulatory Oversight
• Thomas, L. (2021). What is the role of regulatory bodies in health care? https://www.news-medical.net/health/What-is-the-Role-of-Regulatory-Bodies-in-Healthcare.aspx#:~:text=Regulatory%20agencies%20thus%20monitor%20individual,%2C%20state%2C%20and%20federal%20guidelines
• World Health Organization. (n.d.). Patient safety. https://www.who.int/patientsafety/en/
• Wickersham, M. E., & Basey, S. (2016). Is accreditation sufficient? A case study and argument for transparency when government regulatory authority is delegated. Journal of Health and Human Services Administration, 39(2), 245–282.
Tools, Operational Considerations, and Best Practices to Address Safety Threats
• Hooiveld, J., (2022, April 4). Why is incident reporting important for healthcare organizations? The Patient Safety Company. https://www.patientsafety.com/en/blog/why-incident-reporting#:~:text=Incident%20reporting%20in%20healthcare%20refers,mitigate%20risks%2C%20thereby%20reducing%20harm
• Kemper, C., Blackburn, C., Doyle, J. A., & Hyman, D. (2013). Engaging patients and families in system-level improvement: A safety imperative. Nursing Administration Quarterly, 37(3), 203–215.
• Wyatt, R. (2017). Building safe, highly reliable organizations: CQO shares words of wisdom. Biomedical Instrumentation & Technology, 51(1), 65–69.
• Agency for Healthcare Research and Quality. (n.d.). TeamSTEPPS: Team strategies & tools to enhance performance & patient safety. https://www.ahrq.gov/teamstepps/index.html
• National Quality Forum. (n.d.). Serious reportable events. http://www.qualityforum.org/topics/sres/serious_reportable_events.aspx
• Barton, A. J., & Makic, M. B. F. (2015). Technology and patient safety [PDF]. Clinical Nurse Specialist, 29(3), 129–130.
• Jha, A.K. (2018). Accreditation, quality, and making hospital care better. JAMA, 320(23), 2410–2411.
Technology and Patient Safety
The use of technology plays an important role in patient safety.
• Use the Patient Safety Handbook to read the following:
o Chapter 7, “Toward a Philosophy of Patient Safety: Expanding the Systems Approach to Medical Error,” pages 87–97.
o Chapter 23, “Health Information Technology and Patient Safety,” pages 291–297.
• Use The Healthcare Quality Book text to read the following:
o Chapter 7, “Health Information Technology in Healthcare Quality and Safety: Prevention, Identification, and Action,” pages 189–212.
o Chapter 14, “Ambulatory Quality and Safety,” pages 363–376.
APA Style and Library Research
APA Style
All of your assessments in this course must follow the current APA style. You may find it helpful to review the following resources:
• APA Module.
• Academic Honesty & APA Style and Formatting.
• APA Style Paper Tutorial [DOCX].
Health Care Administration Undergraduate Library Research Guide
Consult this resource for guidance on how to conduct research on quality improvement tools and other topics that will help you successfully complete your assessment.
• Health Care Administration Undergraduate Library Research Guide.