Description
Assessment 4 Instructions:
Planning for Change: A Leader’s
Vision
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Develop a presentation, augmented by
12-15 slides, for administrative
leaders and stakeholders that outlines
your plan to develop or enhance a
culture of quality and safety within
your organization or practice setting.
Introduction
Note: Each assessment in this course
builds on the work you completed in
the previous assessment. Therefore,
you must complete the assessments in
this course in the order in which they
are presented.
As a nurse leader, you will be expected
to communicate effectively with
leaders and stakeholders at all levels
in an organization in a variety of ways,
depending on your purpose and your
audience. Being able to deliver
effective presentations is one
important skill you will likely be called
upon to use often.
This assessment provides an
opportunity to hone your presentation
skills and enlist the support of
stakeholder groups who will be key to
achieving desired changes in the
organization and developing or
enhancing a culture of quality and
safety.
This assessment is based on the work
you have completed in the previous
three assessments.
Preparation
The report you completed in the
previous assessment has convinced
the executive leadership team of the
benefits to the organization of taking
the next step toward changes aimed at
improving outcomes and cultivating a
culture of quality and safety. You have
been asked to follow up your report
with a presentation to administrative
leaders and stakeholders that outlines
your plan to develop or enhance the
organization’s culture of quality and
safety. A number of key stakeholders
will be unable to attend your
presentation for a variety of reasons,
so you have decided to provide those
individuals with a video recording of
the presentation.
You have the option of using Kaltura
Media or another technology of your
choice to record your presentation.
If you decide to use Kaltura, you are
encouraged to:
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Install and test your recording
hardware (if you have not
already done so), using the
installation instructions
provided by the manufacturer.
Practice using your recording
hardware to ensure adequate
audio and video quality.
Refer to the Using
Kaltura tutorial for directions
on recording and uploading
your video in the courseroom.
Note: If you require the use of
assistive technology or alternative
communication methods to
participate in this activity, please
contact Disability Services to request
accommodations.
Note: Remember that you can submit
all or a portion of your draft
presentation to Smarthinking for
feedback, before you submit the final
version for this assessment. However,
be mindful of the turnaround time of
24?48 hours for receiving feedback, if
you plan on using this free service.
As you prepare to complete this
assessment, you may want to think
about other related issues to deepen
your understanding or broaden your
viewpoint. You are encouraged to
consider the questions below and
discuss them with a fellow learner, a
work associate, an interested friend,
or a member of your professional
community. Note that these questions
are for your own development and
exploration and do not need to be
completed or submitted as part of
your assessment.
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How might you engage
stakeholders to help develop,
implement, and sustain a vision
to actually change and improve
patient outcomes?
What arguments might be most
effective in obtaining
agreement and support?
What recommendations would
you make to implement a
proposed plan for change?
Requirements
Note: The requirements outlined
below correspond to the grading
criteria in the Planning for Change?A
Leader’s Vision Scoring Guide. Be sure
that your written analysis addresses
each point, at a minimum. You may
also want to read the Planning for
Change?A Leader’s Vision Scoring
Guide and Guiding Questions:
Planning for Change?A Leader’s
Vision [DOCX] to better understand
how each criterion will be assessed.
Developing the Presentation
Summarize the key aspects of a
plan to develop or enhance a
culture of safety.
? Identify existing organizational
functions, processes, and
behaviors affecting quality and
safety.
? Identify current outcome
measures related to quality and
safety.
? Explain the steps needed to
achieve improved outcomes.
? Create a future vision of your
organization’s potential to
develop and sustain a culture of
quality and safety and the nurse
leader’s role in developing that
potential.
Note: If you require the use of
assistive technology or alternative
communication methods to
participate in this activity, please
contact Disability Services to request
accommodations.
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Communication and Supporting
Evidence
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Argue persuasively to obtain
agreement with, and support
for, a plan to develop or
enhance a culture of safety.
Support your main points,
arguments, and conclusions
with relevant and credible
evidence, correctly formatting
citations and references using
APA style.
Additional
Requirements
Your slide deck should consist
of 12?15 slides, including a title
slide and a references slide.
? List your sources on the
references slide at the
end of your presentation.
? Use of a small font is
permitted to fit all 8
references on a single
slide.
Portfolio Prompt: You may choose to
save your presentation to
your ePortfolio.
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Competencies
Measured
By successfully completing this
assessment, you will demonstrate
your proficiency in the following
course competencies and assessment
criteria:
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Competency 1: Analyze quality
and safety outcomes from an
administrative and systems
perspective.
? Summarize the key
aspects of a plan to
develop or enhance a
culture of safety.
Competency 2: Determine how
outcome measures promote
quality and safety processes
within an organization.
? Identify current outcome
measures related to
quality and safety.
Competency 3: Determine how
specific organizational
functions, policies, processes,
procedures, norms, and
behaviors can be used to build
reliability and high-performing
organizations.
? Identify existing
organizational functions,
processes, and behaviors
affecting quality and
safety.
Competency 4: Synthesize the
various aspects of the nurse
leader’s role in developing,
promoting, and sustaining a
culture of quality and safety.
? Explain the steps needed
to achieve improved
outcomes.
? Create a future vision of
an organization’s
potential to develop and
sustain a culture of
quality and safety and
the nurse leader’s role
developing that potential.
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Competency 5: Communicate
effectively with diverse
audiences, in an appropriate
form and style, consistent with
applicable organizational,
professional, and scholarly
standards.
? Argue persuasively to
obtain agreement with,
and support from,
administrative leaders
and stakeholders in an
organization for a plan to
develop or enhance a
culture of safety.
? Support main points,
arguments, and
conclusions with relevant
and credible evidence,
correctly formatting
citations and references
using APA style.
Resources: Patient-Centered
Health Care Concepts
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Patient-Centered Rules to
Improve Quality of Care.
? This short interactive
exercise provides a
useful summary of
patient- and familycentered health care
concepts.
What Happened to Josie?.
? This short video offers a
tragic reminder of the
urgent necessity of
improving patient safety.
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Outcome Measures, Issues, and Opportunities
Elke Guerrero
Capella University
NURS-FPX6212: Health Caare Quality and Safety Management
Professor Mary Ellen Cockerham
February 2nd, 2022
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Outcome Measures, Issues, and Opportunities
The measurement of clinical outcomes helps healthcare organizations deliver valuable
patient care services across the lifespan through the identification of issues and improvement
opportunities. In this regard, these providers require data on clinical practices, processes,
systems, and culture to measure specific outcomes for the target patient population or its entire
client base to achieve this objective. As a result, the management of Washington Hospital has
conducted the Appreciative Inquiry and SWOT Analysis that are useful for measuring
performance outcomes and identifying opportunities for improvement to achieve its strategic
vision. Similarly, this draft report contains an analysis of the functions, processes, and behaviors
in this organization that contributes to its status as a high-performing organization and how these
operational and cultural systems can impact the outcomes of the patient falls prevention project.
Therefore, the report also identified the quality and safety outcomes and performance gaps that
could limit Washington Hospital’s capacity to use the practice changes to harness opportunities
for growth before recommending the strategy to achieve performance targets.
High-Performing Organizations and Outcome Measures
High-performing organizations have operational systems and work culture that
strengthens employee commitment to the shared vision and strategic goals and use them to
evaluate issues that prevent attainment of expected outcomes. Washington Hospital is one of the
high-performing accident and trauma care centers because the work environment promotes
honest and open communication about the quality and safety of patient care and its leaders
provide the resources and support that all stakeholders need to achieve its vision. It is a
perspective that is supported by Ahluwalia et al.’s (2017) view that organizations that enjoy the
highest level of success in their respective industries set performance outcomes that align with
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their mission and vision and create processes and systems that generate them. Washington
Hospital’s recognition as a Magnet facility and receipt of the National Quality Healthcare Award
from the National Quality Forum for three consecutive years represents a continuous investment
in quality improvement initiatives and delivery of excellent healthcare services. Also, the
hospital is reputed for its nursing excellence through its focus on the application of evidencebased nursing care practices and the education and training of its staff. Hence, the hospital has
delivered quality and safe care services that result in positive patient outcomes in all its units.
Despite Washington Hospital’s recognition as a leading provider of acute care,
medical/surgical, and emergency care services, its management strives to identify and implement
innovative and evidence-based practices in all units. It is an approach that is consistent with the
high-performing organization paradigm that requires leaders to evaluate systems and processes
for issues and assess employee behaviors for misalignment with their culture (Kampstra et al.,
2018). In this regard, team leaders, managers, and unit heads are required to conduct
performance surveys and review incident reporting systems to determine safety and quality risks
or issues and propose changes that can prevent or mitigate their impacts. Also, the hospital’s
workers are supported with resources to engage in continuous education programs in their
respective specialties to improve their knowledge, skills, and abilities to deliver the level of
patient-centered care that make the organization a high-performing one. Similarly, this learning
and self-improvement culture has enabled the nurses and physicians to determine innovative and
technology-based approaches for achieving patient outcome targets and meeting quality and
safety standards. Therefore, employees become active contributors to the processes and systems
that are essential for making the relevant practice changes that lead to sustainable growth.
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Furthermore, the result of safety and quality gap analysis for Washington Hospital
showed that the high rate of severe injuries for patient falls is due to some processes, functions,
and behavioral factors that exist in the organization. The view on the link between this
organizational context and this systemic problem is supported by Hagley, Mills, Shiner, and
Hemphill’s (2018) findings from their study on the mitigation of the root causes of high patient
fall rate in acute care settings. According to the researchers, preventable patient falls are
representative of the attitude of the nurses towards prevention protocols and supports that
promote the practice. However, the practice changes that are introduced after the adoption of the
fall prevention toolkit, staff education and training, and the use of an effective incident reporting
system has improved the workers’ behavior and other causes of the problem. Also, nurses’
attitude towards the documentation of high-risk post-operative patients and compliance with the
TIPS protocol is expected to change as management continues to explore innovative and
technology methods for improving patient safety and quality of care. Therefore, the process,
systems, and behaviors are changing towards the quality improvement initiatives that would
close the performance gaps and organizational risks that were discovered in previous
assessments.
Measured Safety and Quality Outcomes
Patient falls rate is a major quality and safety performance indicator for all hospitals.
While the prevention of the near-miss or adverse event requires a multidisciplinary approach to
meet performance targets for accreditation and patient satisfaction, healthcare organizations must
engage in continuous improvement programs to fulfill their mission. Washington Hospital’s
position on this systemic problem is the need to prevent it from having negative consequences on
its strategic value and market share in the region. In this regard, the reduction in the prevalence
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and incidence of severe injuries due to preventable falls in hospitalized patients is one of the
safety and quality outcomes from the improvement initiative that would represent the attainment
of performance goals. It is a measurable outcome of progress towards corporate performance
objectives since it demonstrates the effectiveness of the staff training and education and
compliance with the new protocols. Hence, a substantial reduction in the rate of injuries due to
patient falls in the acute care and acute units are one of the indicators of patient safety and
quality care that would be measured after the implementation of the improvement initiatives.
Furthermore, the patient safety group would utilize the data on the increased cost of care
of hospitalized patients and the extra length of hospital stay as the other measures of the
attainment of safety and quality outcomes at Washington Hospital. These rationales for these
performance indicators were provided in our previous assessment, including the evidence from
previous studies on impacts of patient falls and healthcare care and length of stay. For example,
Gu, Balcaen, Ni, Ampe, and Goffin (2016) stated that an increase of 12 or more days from the
normal length of stay for acute care patients and 61% additional cost of healthcare due to
treatment for injuries during hospitalization show poor nursing care and work culture. It implies
that a post-implementation evaluation of the additional length of stay and cost of inpatient care
are appropriate measures of the positive outcomes of the practice changes and policies that were
introduced as part of this project. The other outcomes from the patient safety and quality of care
improvement project at this hospital that can be measured are patient satisfaction rates, the
number of litigations due to patient falls, and new client enrolment rates. As a result, the
measurement of these outcomes should provide information on the performance issues and
opportunities at Washington Hospital that its leadership, management, and staff can address to
meet immediate and future strategic goals.
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Performance Issues and Opportunities
The financial burdens of the treatment cost of the injuries from falls during
hospitalization are experienced by both patients and the healthcare organization. First, the
average 12 days that are spent in the hospital after a fall increases operational cost by at least 60
percent and healthcare cost to each patient by an estimated $5,000 (Morello et al., 2015). Second,
Medicaid and Medicare’s non-reimbursement policy for preventable patient falls during
hospitalization means that the hospital loses resources to invest in projects and innovations that
could improve quality of care and generate additional revenue. In this regard, the potential
financial performance issues provided the opportunity for the implementation of the fall
prevention project at Washington Hospital with the introduction of new evidence-based
protocols during patient documentation and care. Nurses and other clinical staff began reviewing
the electronic health records for high-risk patients to identify the fall prevention protocol that
meets their needs from June 2021. It is a practice change that was influenced by the mandatory
periodic assessment of acute and post-operative care patients for falls at every stage of their
treatment and documentation of risk scores in their EHR data. As a result of the adoption of these
new protocols, the opportunity for periodic audit of staff compliance rate and other performance
indicators was presented to the patient safety group.
Outline of the Strategy
Additionally, the performance assessment opportunity that was presented by the
introduction of the practice changes for patient falls rate reduction in the acute care units of
Washington Hospital requires an appropriate strategy to achieve quality and safety outcomes.
Also, the right strategy should be based on the right nursing theory to ensure its effectiveness and
alignment with the strategic mission and values of this healthcare organization. These critical
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success factors informed the selection of Lewin’s Change Theory as the right framework to guide
the actions for harnessing the benefits that are presented by the opportunity. According to
Deborah (2018), the change theory consists of core principles that include unfreezing, moving,
and refreezing, which healthcare organizations can utilize for improving the quality of their
processes, systems, and culture. They further added that unfreezing aspect is used to determine
the issues and justify the changes that are needed to improve performance while the moving
principle is the implementation of the interventions and refreezing is the creation of the expected
outcomes from the practice changes. As a result, it projected that the application of the principles
of Lewin’s Theory would promote knowledge sharing that leads to a better understanding of the
significance of staff compliance with the multidisciplinary fall prevention protocols.
Finally, the integration of the principles of the change theory into the efforts for
harnessing the opportunities created by the performance issues involves several actions and
decisions by the leaders of the patient safety group. One of the tasks that are required for the
execution of this strategy is stakeholder engagement to identify the barriers that could impact the
outcomes adversely and resolve them promptly. Second, it is essential to support all relevant
clinical and non-clinical staff with the resources for transiting from the other practice of postsurgical patient documentation to the new ones in the TIPS protocol to eliminate workarounds
and low compliance rates. Third, the strategy is to use the staff training and education sessions to
facilitate communication about the strengths and weaknesses of the new protocol and use the
feedback for improving them to achieve the expected outcomes. Fourth, the outcomes of the
audit of the length of stay and additional cost of care per patient due to injuries during
hospitalization would be presented as part of the periodic monthly reports to increase support for
the project. Overall, the strategy to ensure continuous engagement with all relevant stakeholders,
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provide required resources and support to frontline workers, facilitate authentic communication
and actions, and demonstrate leadership through performance reports.
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References
Ahluwalia, S. C., Damberg, C. L., Silverman, M., Motala, A., & Shekelle, P. G. (2017). What
defines a high-performing health care delivery system: a systematic review. The Joint
Commission Journal on Quality and Patient Safety, 43(9), 450-459.
https://doi.org/10.1016/j.jcjq.2017.03.010
Deborah, O. K. (2018). Lewin?s Theory of Change: Applicability of its Principles in a
Contemporary Organization. Journal of Strategic Management, 2(5), 1-12.
Gu, Y. Y., Balcaen, K., Ni, Y., Ampe, J., & Goffin, J. (2016). Review on prevention of falls in
hospital settings. Chinese nursing research, 3(1), 7-10.
https://doi.org/10.1016/j.cnre.2015.11.002
Hagley, G. W., Mills, P. D., Shiner, B., & Hemphill, R. R. (2018). An analysis of adverse events
in the rehabilitation department: Using the Veterans Affairs root cause analysis
system. Physical therapy, 98(4), 223-230.
Kampstra, N. A., Zipfel, N., van der Nat, P. B., Westert, G. P., van der Wees, P. J., &
Groenewoud, A. S. (2018). Health outcomes measurement and organizational readiness
support quality improvement: a systematic review. BMC health services research, 18(1),
1-14. https://doi.org/10.1186/s12913-018-3828-9
Morello, R. T., Barker, A. L., Watts, J. J., Haines, T., Zavarsek, S. S., Hill, K. D., … &
Stoelwinder, J. U. (2015). The extra resource burden of in-hospital falls: a cost of falls
study. Medical journal of Australia, 203(9), 367-367.
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