Safety Score Improvement Plan

Refer to the Capella library and the Internet for supplemental resources to help you complete this assessment, a safety score improvement plan.

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:

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.

Resources

Suggested Resources

The following optional resources are provided to support you in completing the assessment or to provide a helpful context. For additional resources, refer to the Research Resources and Supplemental Resources in the left navigation menu of your courseroom.

Capella Media

Click the link provided below to view the following multimedia piece:

• Systems Theory and the Fifth Discipline | Transcript.

SYSTEMS THEORY AND THE FIFTH DISCIPLINE

Intro

Peter Senge’s vision of a learning organization has been deeply influential. Self described as an idealistic pragmatist, Senge’s orientation allowed him to explore and advocate some utopian and abstract ideas—especially about systems theory and the necessity of bringing human values to the workplace. He was also able to translate these issues for application in very different organizations.

In The Fifth Discipline, Senge explains that systems thinking is particularly important because it connects the disciplines together and helps explain the complex behavior and outcomes that occur in organizations. It also illuminates feedback loops—growth cycles, control cycles, and delays that drive organizational systems. Senge’s book gives us a language for understanding these systems and explaining their dramatic successes and failures.

Senge’s second installment, The Fifth Discipline Fieldbook, is filled with practical tips and real-life examples from companies and organizations that have embraced organizational learning successfully. In this book, Senge asserts that the practice of organizational learning involves developing and taking part in tangible activities that will change the way people think and interact.

This presentation provides a high level overview to Senge’s five disciplines Click on each section to learn more about each discipline.

Personal Mastery

This discipline of aspiration involves formulating a coherent picture of the results people most desire to gain as individuals (their personal vision), alongside a realistic assessment of the current state of their lives today (their current reality). Learning to cultivate the tension between vision and reality (represented in this icon by the rubber band) can expand people’s capacity to make better choices, and to achieve more of the results that they have chosen.

Mental Models

This discipline of reflection and inquiry skills is focused around developing awareness of the attitudes and perceptions that influence thought and interaction. By continually reflecting upon, talking about, and reconsidering these internal pictures of the world, people can gain more capability in governing their actions and decisions. One example of this discipline is the “ladder of inference,” which depicts how people leap instantly to counterproductive conclusions and assumptions.

Shared Vision

This collective discipline establishes a focus on mutual purpose. People learn to nourish a sense of commitment in a group or organization by developing shared images of the future they seek to create and the principles and guiding practices by which they hope to get there.

Team Learning

This is a discipline of group interaction. Through techniques like dialogue and skillful discussion, teams transform their collective thinking, learning to mobilize their energies and ability greater than the sum of individual members’ talents.

Systems Thinking

In this discipline, people learn to better understand interdependency and change, and thereby to deal more effectively with the forces that shape the consequences of our actions. Systems thinking is based upon a growing body of theory about the behavior of feedback and complexity-the innate tendencies of a system that leads to growth or stability over time. Tools and techniques such as systems archetypes and various types of learning labs and simulations help people see how to change systems more effectively, and how to act more in tune with the larger processes of the natural and economic world.

REFERENCES

• Senge, P. (1990). The fifth discipline: The art and practice of the learning organization. New York, New York: Currency Doubleday Publications.
• Senge, P. (1994). The fifth discipline fieldbook. New York, New York: Currency Doubleday Publications.
• Smith, M.K. (2001). Peter Senge and the learning organization. Retrieved July 15, 2008 from http://www.infed.org/thinkers/senge.htm
• Society of Organizational Learning. (n.d.) The five disciplines of organizational learning. Retrieved July 15, 2008 from http://www.solonline.org/organizational_overview/

Subject Matter Expert:John HerrInteractive Designer:Alyssa WilcoxInstructional Designer:Tiffany HerderProject Manager:Catherine Baumgartner

The following e-books or articles from the Capella University Library are linked directly in this course:Library Resources

• Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education for nurses (QSEN): The key is systems thinking. Online Journal of Issues in Nursing, 18(3), 71–80.
• Kim, D. H., & Senge, P. M. (1994). Putting systems thinking into practice. System Dynamics Review, 10(2/3), 277–290.
• Sullivan, D. T. (2010). Connecting nursing education and practice: A focus on shared goals for quality and safety. Creative Nursing, 16(1), 37–43.
• 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.
• Squires, M., Tourangeau, A., Laschinger, H. K. S., & Doran, D. (2010). The link between leadership and safety outcomes in hospitals. Journal of Nursing Management, 18(8), 914–925.
• Morath, J. (2011). Nurses create a culture of patient safety: It takes more than projects. Online Journal of Issues in Nursing, 16(3), 2.
• Gagnon, M-P., Desmartis, M., Labrecque, M., Car, J., Pagliari, C., Pluye, P., . . . Légaré, F. (2012). Systematic review of factors influencing the adoption of information and communication technologies by healthcare professionals. Journal of Medical Systems, 36(1), 241–277.
• Melnyk, B. M., Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan, L. (2012). The state of evidence-based practice in US nurses: Critical implications for nurse leaders and educators. The Journal of Nursing Administration, 42(9), 410–417.
• Stimpfel, A. W., & Aiken, L. H. (2013). Hospital staff nurses’ shift length associated with safety and quality of care. Journal of Nursing Care Quality, 28(2), 122–129.

Course Library Guide

A Capella University library guide has been created specifically for your use in this course. You are encouraged to refer to the resources in the BSN-FP4008 – Organizational and Systems Management for Quality Outcomes Library Guide to help direct your research.

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/

Bookstore Resources

The resources listed below are relevant to the topics and assessments in this course and are not required. Unless noted otherwise, these materials are available for purchase from the Capella University Bookstore. When searching the bookstore, be sure to look for the Course ID with the specific –FP (FlexPath) course designation.

• Huber, D. L. (2014). Leadership and nursing care management (5th ed.). Maryland Heights, MO: W. B. Saunders.
  • Chapter 24.
  • Chapter 25.
  • Chapter 34.
  • Chapter 36.

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.

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.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.

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/

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.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

• Competency 1: Identify nursing leadership priorities using a systems perspective.
  • Identify a patient safety issue.
• Competency 2: Apply systems theory and systems thinking to facilitate health care delivery and patient outcomes.
  • Apply systems thinking to explain how current policies and procedures may affect a safety issue.
  • Explain a strategy to collect information about the safety concern.
  • Explain a plan to implement a recommendation and monitor outcomes.
  • Recommend an evidence-based strategy to improve the safety issue.
• Competency 4: Evaluate how power relates to health care organizational structure, behavior, and leadership.
  • Describe the influence of nursing leadership in driving the needed changes.
• Competency 5: Communicate in a manner that is consistent with the expectations of a nursing professional.
  • Write content clearly and logically, with correct use of grammar, punctuation, and mechanics.
  • Correctly format citations and references using current APA style.

Reference

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.

Safety Score Improvement Plan Scoring Guide

CRITERIA	NON-PERFORMANCE	BASIC	PROFICIENT	DISTINGUISHED
Identify a patient safety issue.	Does not identify a patient safety issue.	Identifies patient safety concerns in general, but does not identify a specific issue.	Identifies a patient safety issue.	Identifies a patient safety issue and explains why the issue is a primary concern for nursing.
Describe the influence of nursing leadership in driving needed changes.	Does not describe the influence of nursing leadership in driving the needed changes.	Describes the influence of nursing leadership in general terms but does not describe how nursing leadership can drive change.	Describes the influence of nursing leadership in driving the needed changes.	Describes the influence of nursing leadership as a driving force for changes that affect patient safety and quality outcomes, and provides a specific example of driving a needed change.
Apply systems thinking to explain how current policies and procedures may affect a safety issue.	Does not apply systems thinking to explain how current policies and procedures may affect a safety issue.	Identifies leadership and structure responsible for current policies and procedures, but does not apply systems thinking to explain the connection to patient safety.	Applies systems thinking to explain how current policies and procedures may affect a safety issue.	Applies systems thinking to explain how current policies and procedures may affect a safety issue, and includes a discussion of how staff could monitor systems and implement safeguards.
Explain a strategy to collect information about the safety concern.	Does not explain a strategy to collect information about the safety concern.	Identifies several strategies to collect information about the safety concern, but does not explain one strategy.	Explains a strategy to collect information about the safety concern.	Explains a strategy to collect information about the safety concern and how it could be implemented, and identifies possible obstacles to obtaining information.
Recommend an evidence-based strategy to improve the safety issue.	Does not recommend an evidence-based strategy to improve the safety issue.	Describes strategies for improving a safety issue, but does not indicate if it is evidence based.	Recommends an evidence-based strategy to improve the safety issue.	Recommends an evidence-based strategy to improve the safety issue, and identifies potential limitations of the strategy.
Explain a plan to implement a recommendation and monitor outcomes.	Does not explain a plan to implement a recommendation and monitor outcomes.	Makes a recommendation, but does not explain how it will be implemented.	Explains a plan to implement a recommendation and monitor outcomes.	Explains a plan to implement a recommendation and monitor outcomes, and specifies quality indicators and accountable staff.
Write content clearly and logically, with correct use of grammar, punctuation, and mechanics.	Does not write content clearly and logically, and there are errors in grammar, punctuation, and mechanics.	Writes with errors in clarity, logic, grammar, punctuation, or mechanics.	Writes content clearly and logically, with correct use of grammar, punctuation, and mechanics.	Writes clearly and logically, with correct use spelling, grammar, punctuation, and mechanics, and uses relevant evidence to support a central idea.
Correctly format citations and references using current APA style.	Does not correctly format citations and references using current APA style.	Uses current APA to format citations and references but with numerous errors.	Correctly formats citations and references using current APA style with a few errors.	Correctly formats citations and references with no errors.

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