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NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

Student Name Capella University NURS-FPX 6212 Health Care Quality and Safety Management Prof. Name Date Planning for a Change: A Leader’s Vision Hello everyone, I am ——, and I welcome you all to this presentation on planning for a change in minimizing medication errors. Presentation Agenda   This presentation will provide the primary plan to revamp outcomes and foster a culture of quality and safety within a healthcare organization. For this purpose, first, I would like to review the importance of safety and quality outcomes in healthcare organizations and then summarize critical aspects of the plan that ensure an enhanced safety culture. Then we will begin discussing how the existing organizational functions, processes, and behaviors impact safety and quality regarding medication errors. Then, we will cover existing outcome measures regarding quality and safety, followed by the required ways to attain improved health outcomes. Lastly, we will create an organizational future vision on developing and preserving a safety culture and how nurse leaders can play an influential role in developing this culture. So, let’s begin. Importance of Safety and Quality Outcomes in Healthcare Systems Safety and quality outcomes are the cornerstones of every healthcare organization to ensure patients’ safety and well-being. Acquiring good quality care and treatment is a basic right of every patient, and it is the hospital’s responsibility to provide patients with appropriate and timely care treatments to lower the risk of medical errors and relevant complications. Moreover, safe and high-quality care treatments improve patient satisfaction and impart public trust in healthcare systems and their services (WHO, 2021). Healthcare organizations can retain professionals when safety and quality care outcomes are achieved as the care providers get a supportive environment where the primary goal is to deliver safe and high-quality care treatment to patients. Additionally, when the quality of care brings safe and quality outcomes, it aligns with the ethical principles of care treatment by preventing harm and delivering the proper treatment to the right people leading to the best possible health outcomes. Key Aspects of Plan to Achieve Culture of Safety In achieving a culture of safety while providing medication treatment in a healthcare organization, it is crucial to include several aspects of care treatment, such as: These critical aspects significantly promote a safety culture while managing medication in the clinical care setup. Healthcare organizations must endeavor to consider and integrate these aspects into practice to achieve quality and safety outcomes and reduce medication errors. Existing Organizational Processes, Functions, and Behaviors Influencing Quality and Safety There are various existing organizational functions, processes and behaviors that impact the quality and safety of medication management. I will discuss a few of these functions and behaviors in terms of medication management which lead to medication errors adversely impacting the quality of care and patient safety, along with the possible solutions to tackle these functions and behaviors. Lack of interdisciplinary collaboration and communication is a significant cause of medication errors as proper communication is not ensured, which leads to misunderstandings, non-clarity, and confusion in medication management, the consequences of which have to be significantly tolerated by the patient. This behavioral issue can be tackled by implementing electronic health records (EHR), so all healthcare professionals are aligned with the medication history, prescribed drugs and related information to manage medication.  Furthermore, the existing functions that rely on traditional methods of medication prescription, dispensing and administration are more vulnerable to the onset of medication-associated adverse events. The traditional methods for medication management may result in medication errors due to prescription, transcription, dispensing and administration. This can be overcome by safety and risk management through the integration of modern technologies that reduce the risks of medication errors. These technologies include barcode medication administration (BCMA), Automated Dispensing Cabinets (ADC) and computerized physician order entry (CPOE) (Carver et al., 2019). Moreover, preventive measures that ensure medication safety and improve the quality of care and patient safety can be used proactively before adverse situations arise. Likewise, high-performing organizations which promote staff education and training on medication reconciliation and management and integrate leadership and interprofessional collaboration principles (Guisado-Gil et al., 2019), our organization can utilize such effective measures as well. These changes in processes and behaviors will ensure effective collaboration, manage risk, positively impact care quality, and enhance patient safety. Knowledge Gaps, Unknown and Missing Information The knowledge gaps, unknown and missing information that hinder an accurate analysis of present organizational functions, processes and behaviors that impact quality and safety include information about existing resources to initiate sustainability plans, leadership commitment towards the change-making, and staff acceptance for the change. Further research and information are required to better analyze the successful operations of these processes and behaviors in a healthcare organization. Current Outcome Measures In this section, we will discuss the current outcome measures related to the safety and quality of medication management, along with their weaknesses and strengths. Healthcare organizations are currently using various outcome measures to evaluate the safety and quality of medication management. These outcome measures include patient harm, mortality rates, and patient satisfaction based on the type of medication errors, such as prescription errors, dispensing errors and administration errors that cause these safety and quality outcomes. Some healthcare systems use medication reconciliation accuracy and hospital readmission rates as outcome measures. Patient harm reveals the clinical impact a medication error imposes on the patient, along with severity grading in terms of mild harm, moderate harm, severe harm or death. Mortality rates occurring due to medication errors; tell the severity of medication errors and guide healthcare organizations on reducing mortality rates through root-cause analysis. The lower patient satisfaction rates depict poor quality and safety in providing care treatment and medication management due to several factors, including medication errors. By finding the data on these outcome measures, healthcare professionals can evaluate the rooms for improvement; for example, patient satisfaction and patient harm direct healthcare staff to take preventive measures to ensure safe and right medication management is delivered to patients as per their health needs. Likewise, mortality rates can guide

NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

Student Name Capella University NURS-FPX 6212 Health Care Quality and Safety Management Prof. Name Date Outcomes, Measures, Issues, and Opportunities This draft report directs the outcome measure and opportunities, including a change model strategy that measures all patient care aspects. Medication errors are preventable adverse events that cause 44,000 to 98,000 mortalities in U.S. healthcare organizations annually. Out of every 100 admissions, 6.5 patients experience medication error-related adverse events in acute care hospitals (Carver et al., 2019). There are different types of medication errors, such as medication errors in the peri-discharge period, prescription, transcription, administration, and monitoring errors. These errors impact patients’ health in one way or another, resulting in various adverse health outcomes such as disabilities, paralysis, comorbidities, and mortalities. Therefore, it is essential to identify performance issues, evaluate outcomes, measures, and opportunities to tackle these issues, and make prospective improvements to promote medication safety. Organizational Functions, Processes, and Behaviors in High-Performing Organizations High-performing healthcare organizations work for continuous improvements and identify potential opportunities for betterment. To prevent medication errors, high-performance healthcare setups implement training and educational programs to ensure the healthcare staff is well aware of medication safety and the risks of medication errors. The healthcare authorities develop and implement various plans and strategies, including incidence reporting systems and technology-based medication management, to achieve safe medication administration and monitoring. Furthermore, healthcare organizations promote medication reconciliation at times of transition of care and admission, using computerized physician order entry (CPOE), clinical decision support systems (CDSS), EHR, and barcode medication administration (BCMA) (Carver et al., 2019). These processes and functions help healthcare professionals minimize medication errors due to prescription, transcription, administration, and monitoring.  High-performing organizations promote a blame-free environment to encourage immediate reporting of medication errors through incidence reporting systems. Moreover, these organizations ensure that adequate healthcare staff is available to reduce staff burnout which contributes to the incidence of medication errors (Kwon et al., 2021). Another way high-performing organizations promote medication safety is by fostering a culture of leadership roles where team leads communicate effectively with other staff members on medication management and safe administration to keep all actions aligned (Ledlow et al., 2023). The identified knowledge gaps and uncertainty areas that hinder this analysis include how these organizations maintain these functions and processes during resource downturns and economic constraints. Additionally, how these organizations manage the nurse shortage and increased turnover rates and prevent medication errors during these circumstances requires further information to improve the analysis. Determining Impact of Organizational Functions, Processes, and Behaviors on Outcome Measures Healthcare organizational functions, processes, and behaviors related to medication errors and their prevention impact outcome measures positively and negatively that directly impact patient safety. For instance, a healthcare organization with a robust leadership and governance role prioritizes medication errors by providing effective guidelines on medication safety, adequate allocation of resources, and training, that facilitates safe medication management. This supports positive health outcomes for patients by reducing medication errors. Likewise, organizational behaviors that support blame-free reporting of medication errors encourage healthcare professionals to report and learn from adverse events related to medication error and ensures prompt action to mitigate adverse events related to medication errors. Furthermore, the implementation of barcode medication administration (BCMA) identifies the right patient with the right medication prescribed through barcode matching. It promotes safe medication administration, enhancing patient safety and satisfaction (Mulac et al., 2021). Contrarily, the lack of leadership, interprofessional collaboration, and transparent communication on medication management adversely affects health outcomes as the medication error rates increase. An organizational culture that imposes penalties and termination to healthcare professionals on the incidence of medication errors leads to under-reporting and further progresses medication errors and patient harm (Musharyanti et al., 2019). These processes and behaviors of an organization impact outcomes about medication errors leading to high medication-associated mortality rates. The assumptions and reasons on which determination is based include that appropriate preventive measures for medication errors like technology use, leadership, and accountability governance promotes safe medication administration and management. Moreover, the need for interprofessional collaboration, hands-off communication, and technology-based medication management promotes medication errors.  Quality and Safety Outcomes with Associated Measures Types of Medication Errors  Medication Errors Associated Quality and Safety Outcomes Data Obtained in 2022 Preventive Measures Prescribing Errors  Patient Harm  30% Patient harms due to prescription errors can be reduced by hands-off communication on medication management and use of computerized physician order entry (CPOE) to avoid misunderstandings due to handwritten prescriptions. Mortality Rate 10%  Mortality rates due to prescription errors can be reduced by implementing medication reconciliation during care transitions and involving the interprofessional teams to align with medication management, including physicians, nurses, and pharmacists.  Patient Satisfaction 7%  Due to prescription errors, patient satisfaction reduces, which requires appropriate care treatment provision by clinical decision support systems to align medication management procedures and minimize prescription errors and improve patient satisfaction through the right medication management (Sutton & Pincock, 2020).  Dispensing Errors Patient Harm 30%  Implement double-check strategy to avoid dispensing errors  and promote pharmacist involvement in ensuring drug accuracy and dosage calculation to reduce patient harm due to dispensing errors.  Mortality Rate 20% Use technology-based systems such as automated dispensing through robotic systems and promote double-check and confirm labeling and packaging so that dispensing mistakes are reduced and mortality rates due to dispensing errors can be declined.  Patient Satisfaction 5%  Reducing dispensing errors and providing correct care treatment by well medication management will enhance patient satisfaction Administration Errors Patient Harm 35%  Training nurses on the right medication administration techniques to avoid patient harm due to administration errors. Medication reconciliation during care transitions ensures accurate information on patient medication, providing fewer chances of medication errors as the right remedy will be administered and patient safety will be improved, reducing the mortality rates (Guisado-Gil et al., 2019).  Mortality Rates 20% Implement double-checks, confirm medication with patient’s prescription to prevent wrong administration, and use BCMA technology to ensure safe medication administration and reduce mortality rates  Patient Safety 6% Technology-based systems like BCMA help reduce administration errors and ensure patient safety (Carver

NURS FPX 6212 Assessment 2 Executive Summary

Student Name Capella University NURS-FPX 6212 Health Care Quality and Safety Management Prof. Name Date Executive Summary Healthcare-associated infections (HAIs) represent adverse events in healthcare organizations, impacting the quality of care and patient safety. This assessment focuses on summarizing key strategies for executives at Vila Health to address identified HAIs and bridge the gap between current and desired outcomes. Key Quality and Safety Outcome Measures Hospital-acquired infections (HAIs) lead to negative consequences such as prolonged hospital stays, increased financial burdens, and elevated risks of morbidities and mortality (Stewart et al., 2021). To measure quality and safety outcomes, Vila Health will assess infection rates, antibiotic resistance, morbidity and mortality rates, patient safety indicators, and cost/resource utilization. These measures provide objective data for infection control, antibiotic stewardship, and overall improvement in patient safety. Strategic Value of Outcome Measures for an Organization Monitoring outcome measures is crucial for enhancing care quality and fostering a safety culture at Vila Health. These measures, including infection rates and patient safety indicators, aid in analyzing care effectiveness, healthcare professional efficiency, and patient experiences. Strategic interventions based on these measures can optimize resource utilization, shorten hospital stays, and alleviate financial burdens, ultimately cultivating a culture of quality improvement and patient safety. Relationship Between Systemic Problems and Quality and Safety Outcomes HAIs are common in healthcare facilities, necessitating continuous monitoring of infection rates, antibiotic resistance, and patient safety indicators. These measures are intertwined with systemic problems, guiding the identification of areas for improvement in practices and the introduction of interventions, such as antibiotic stewardship, to minimize HAIs. Outcome Measures and Strategic Initiatives Vila Health’s strategic plan focuses on improving healthcare practices and patient satisfaction. The outlined outcome measures align with this approach, providing insights into infection rates, antibiotic resistance, morbidity/mortality rates, and patient safety indicators. These measures act as tools to create a patient-centric culture, emphasizing quality healthcare and satisfaction. Leadership Role in the Implementation of Proposed Practice Changes Effective leadership is vital for implementing proposed change strategies. Leaders at Vila Health should establish a clear vision, communicate openly with the team, and encourage interprofessional collaboration. These leadership strategies ensure successful implementation, sustainability, and continuous improvement of proposed interventions. Conclusion Outcome measures, including infection rates and patient safety indicators, are essential for identifying areas of improvement in healthcare organizations. For Vila Health, these measures align with strategic goals, promoting a patient-centric culture and providing a framework for successful change implementation. Leadership plays a critical role in fostering a culture of continuous improvement and patient safety. References Gochmann, V., Stam, D., & Shemla, M. (2022). The boundaries of vision communication—the effects of vision‐task goal‐alignment on leaders’ effectiveness. Journal of Applied Social Psychology, 52(5), 263–276. Hansen, S., Schwab, F., Zingg, W., & Gastmeier, P. (2018). Process and outcome indicators for infection control and prevention in European acute care hospitals in 2011 to 2012 – results of the prohibit study. Eurosurveillance, 23(21). NURS FPX 6212 Assessment 2 Executive Summary Izadi, N., Etemad, K., Mehrabi, Y., Eshrati, B., & Hashemi Nazari, S. S. (2021). The standardization of hospital-acquired infection rates using prediction models in Iran: Observational study of national nosocomial infection registry data. JMIR Public Health and Surveillance, 7(12). Lakoh, S., Li, L., Sevalie, S., Guo, X., Adekanmbi, O., Yang, G., Adebayo, O., Yi, L., Coker, J. M., Wang, S., Wang, T., Sun, W., Habib, A. G., & Klein, E. Y. (2020). Antibiotic resistance in patients with clinical features of healthcare-associated infections in an urban tertiary hospital in Sierra Leone: A cross-sectional study. Antimicrobial Resistance & Infection Control, 9(1). MacGillivray, T. E. (2020). Advancing the culture of patient safety and quality improvement. Methodist DeBakey Cardiovascular Journal, 16(3), 192. Pantaleon, L. (2019). Why measuring outcomes is important in health care. Journal of Veterinary Internal Medicine, 33(2), 356–362. NURS FPX 6212 Assessment 2 Executive Summary Simons, M., Goossensen, A., & Nies, H. (2022). Interventions fostering interdisciplinary and inter-organizational collaboration in health and Social Care; an Integrative Literature Review. Journal of Interprofessional Education & Practice, 28, 100515. Stewart, S., Robertson, C., Pan, J., Kennedy, S., Haahr, L., Manoukian, S., Mason, H., Kavanagh, K., Graves, N., Dancer, S. J., Cook, B., & Reilly, J. (2021). Impact of healthcare-associated infection on length of stay. Journal of Hospital Infection, 114, 23–31. Tokareva, I., & Romano, P. 2. (2023, April 26). Patient safety indicators. AHRQ Patient Safety Network.

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Student Name Capella University NURS-FPX 6212 Health Care Quality and Safety Management Prof. Name Date Quality and Safety Gap Analysis – Hospital-Acquired Infections Healthcare organizations globally exert considerable effort to uphold healthcare quality standards and enhance patient safety. Despite these efforts, challenges persist within healthcare practices, often stemming from adverse events in the healthcare system. One such challenge is hospital-acquired infections (HAIs), which compromise the quality of care and pose risks to patient safety. Recently identified in the Vila Health organization during a quality and safety assurance audit, HAIs prompted administrators to task nurse leaders with analyzing the gap between current and desired outcomes in terms of improving quality and safety. Systemic Problems Related to Quality and Safety Outcomes Hospital-acquired infections (HAIs) are infections occurring within healthcare settings, typically manifesting 48 hours after a patient’s admission (Monegro et al., 2023). Predominantly caused by inadequate care and healthcare provider malpractices, these infections affect approximately 8.7% of hospitalized patients, with urinary tract infections being particularly prevalent (World Health Organization [WHO], n.d.). HAIs lead to adverse consequences, such as prolonged hospital stays, increased morbidity risks, financial burdens for both hospitals and patients, and in severe cases, long-term complications and death (Stewart et al., 2021). Addressing this issue is imperative to ensure quality healthcare, maintain patient safety, and improve health outcomes. Key assumptions guiding this endeavor include the necessity for collaborative approaches to healthcare organizational change and the importance of healthcare providers gaining insight to effect successful practice changes. Practice Changes to Improve Quality and Safety Outcomes To enhance patient outcomes, specifically addressing healthcare-associated infections, it is crucial to propose practice changes within healthcare organizations. The Targeted Assessment for Prevention (TAP) strategy, established by the Centers for Disease Control and Prevention (CDC, 2023), offers a three-step approach involving organizational targeting, needs assessment, and the implementation of prevention strategies. Priority transformations include: 1) proper utilization of personal protective equipment (PPE) to reduce occupational transmission risks (Alhumaid et al., 2021), 2) adherence to WHO’s hand hygiene guidelines by healthcare workers, including hand rubbing and glove usage (WHO, n.d.), 3) improvement of environmental hygiene through audits and quality assurance practices, and 4) training healthcare professionals to implement these changes through regular in-service sessions. This proposal assumes that infection control practices play a pivotal role in minimizing infection risks and improving healthcare outcomes. Prioritization of the Proposed Change Strategies While each proposed change strategy is vital, prioritizing hand hygiene practices and healthcare professional education is recommended. Effectively implementing these guidelines can significantly enhance infection control practices, preventing HAIs. Prioritizing hand hygiene is justified by hands being a primary source of germ transmission, and CDC asserts that proper hand hygiene inhibits the spread of antibiotic-resistant infections, emphasizing its crucial role in patient safety regarding HAIs. Quality and Safety Culture and its Evaluation The suggested change strategies contribute to improving care quality and fostering a safety culture through advancements in healthcare practices. Success hinges on encouraging interprofessional collaboration, communication, and cultivating a mindset of continuous improvement. Preventing nosocomial infections positively impacts care quality, reducing financial burdens, shortening hospital stays, minimizing complications, and enhancing patient satisfaction and safety. Evaluation metrics include continuous prevalence surveys, measuring patient satisfaction levels, and assessing staff knowledge to gauge the effectiveness of the proposed change strategies and the established quality and safety culture. Organizational Culture Affecting Quality and Safety Outcomes The culture and hierarchy of a healthcare organization significantly impact adverse outcomes in quality and safety. Inadequate communication lines impede the identification of adverse events like HAIs, negatively affecting quality and safety. Improved communication, sufficient staffing, and fostering a positive and accountable culture are crucial for effective infection control and improved patient safety. Teamwork and collaboration are deemed essential for implementing and managing change in healthcare settings. Justification of Necessary Changes in an Organization Organizational changes are essential to mitigate adverse quality and safety outcomes. Establishing an interprofessional committee, implementing a zero-tolerance policy for negligence, and ensuring adequate resources for infection control practices are crucial. The interprofessional committee, comprising nurse leaders, quality assurance personnel, and administrators, is tasked with monitoring practices, motivating staff adherence to standards, promoting patient-centered care, and identifying areas for improvement. The zero-tolerance policy holds healthcare workers accountable for inadequate infection control, and collaboration with internal and external stakeholders is essential for securing necessary resources. References Alhumaid, S., Al Mutair, A., Al Alawi, Z., Alsuliman, M., Ahmed, G. Y., Rabaan, A. A., Al-Tawfiq, J. A., & Al-Omari, A. (2021). Knowledge of infection prevention and control among healthcare workers and Factors Influencing Compliance: A systematic review. Antimicrobial Resistance & Infection Control, 10(1).  Baumbach, L., Frese, M., Härter, M., König, H.-H., & Hajek, A. (2023). Patients satisfied with care report better quality of life and self-rated health—cross-sectional findings based on hospital quality data. Healthcare, 11(5), 775.  Bearman, G., Doll, M., Cooper, K., & Stevens, M. P. (2019). Hospital infection prevention: How much can we prevent and how hard should we try? Current Infectious Disease Reports, 21(1). NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis  Centers for Disease Control and Prevention. (2023, April 3). The Targeted Assessment for Prevention (TAP) strategy. Centers for Disease Control and Prevention.  Mello, M. M., Frakes, M. D., Blumenkranz, E., & Studdert, D. M. (2020). Malpractice liability and health care quality. JAMA, 323(4), 352.  Mitchell, B. G., Gardner, A., Stone, P. W., Hall, L., & Pogorzelska-Maziarz, M. (2018). Hospital staffing and healthcare–associated infections: A systematic review of the literature. The Joint Commission Journal on Quality and Patient Safety, 44(10), 613–622.  Monegro, A. F., Muppidi, V., & Regunath, H. (2023). Hospital-acquired infections. In StatPearls. StatPearls Publishing.  Stewart, S., Robertson, C., Pan, J., Kennedy, S., Haahr, L., Manoukian, S., Mason, H., Kavanagh, K., Graves, N., Dancer, S. J., Cook, B., & Reilly, J. (2021). Impact of healthcare-associated infection on length of stay. Journal of Hospital Infection, 114, 23–31.  Sun, J., Qin, W., Jia, L., Sun, Z., Xu, H., Hui, Y., Gu, A., & Li, W. (2021). Analysis of continuous prevalence survey of healthcare-associated infections based on the real-time monitoring system