Analyze three safety and quality results you found for the hospital such as: HCAHPS, pneumonia care, and emergency room treatment times. Describe the process and procedure used to access the data including a description of at least two websites that provide the data used.

Overview

In this Work Product Assessment, you will evaluate patient safety and quality data for a healthcare organization to identify an opportunity for error prevention. Based on this data, you will perform a Failure Mode and Effects Analysis (FMEA) to determine three probable causes for the errors. Then, you will develop a patient safety plan to help reduce the number of errors.

To complete this Assessment:

Download the Academic Writing Expectations Checklist to use as a guide when completing your Assessment. Responses that do not meet the expectations of scholarly writing will be returned without scoring. Properly formatted APA citations and references must be provided, where appropriate.
Be sure to use scholarly academic resources as specified in the rubric. This means using Walden Library databases to obtain peer reviewed articles. Additionally, .gov (government expert sources) are a quality resource option. Note: Internet and .com sources do not meet this requirement. Contact your coach or SME for guidance on using Library Databases.
Carefully review the rubric for the Assessment as part of your preparation to complete your Assessment work.

This Assessment requires submission of one (1) document for all three parts of your Final Assessment. Save your file as OM004_firstinitial_lastname (for example, OM004_J_Smith).

When you are ready to upload your completed Assessment, use the Assessment tab on the top navigation menu.

Instructions

Before submitting your Assessment, carefully review the rubric. This is the same rubric the assessor will use to evaluate your submission and it provides detailed criteria describing how to achieve or master the Competency. Many students find that understanding the requirements of the Assessment and the rubric criteria help them direct their focus and use their time most productively.

Access the following to complete this Assessment:
Academic Writing Expectations Checklist
The assessment has three-parts. Click each of the items below to complete this assessment.

Part I: Analysis of Patient Safety and Quality of Services in a Hospital

In an increasingly consumer-driven healthcare system that is focused on safety and quality of services, patients and healthcare professionals alike are able to access reliable data about the quality and safety records of organizations. Healthcare administrators can look at how their organizations are faring within specific categories and compare results with those of other institutions. As part of this Assessment, you will analyze this data to determine areas within a healthcare organization in need of additional improvement.

For this Assessment, select a hospital you work for or one that has been awarded the Baldridge Performance Excellence Award. In preparation for developing a patient safety plan, use data found on websites, such as the Leapfrog Group Hospital Safety Grade; Hospital Compare, maintained by the Centers for Medicare & Medicaid Services (CMS); and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Hospital Survey, to review the wide range of issue-specific data aligned to patient safety, quality of services, and patient satisfaction.

In a 1- to 2-page analysis:

Analyze three safety and quality results you found for the hospital such as: HCAHPS, pneumonia care, and emergency room treatment times.

Describe the process and procedure used to access the data including a description of at least two websites that provide the data used.

Leapfrog Hospital Safety Grade | Leapfrog (leapfroggroup.org)

Find Healthcare Providers: Compare Care Near You | Medicare
Home (hcahpsonline.org)

Part II: Failure Mode and Effects Analysis

Complete the FMEA (Failure Mode and Effects Analysis) Template, the fourth PDF under the “Download Documents” heading located at the bottom of the Institute of Healthcare Improvement website. To access the actual tool, you must complete an IHI registration (no cost). Use the tool to look for a weak link in the quality chain. Look beyond direct care for things that could contribute to the error. Think organizationally to trace the problem back to the original cause. Rate possible events that could go wrong.

Quality Improvement Essentials Toolkit | IHI – Institute for Healthcare Improvement

Part III: Patient Safety Plan Proposal

Based on the results of Part 1 and Part 2, select three areas related to patient safety or quality in need of additional training or support. Then, create a 3- to 5-page proposal in which you:

Design a patient safety plan to address three areas of focus from the results of the FMEA.
Describe an evaluation method to assess whether the patient safety plan is successful.

OM004 Improving Patient Safety and Quality of Services

Over the past several years, the healthcare industry has embraced new practices, methodologies, and procedures for ensuring patient safety and improving quality of care. Healthcare leaders recognize that this is a continual process, and one that is both dynamic and complex. Many third-party organizations have evolved to assist, assess, and accredit healthcare organizations for meeting quality and safety benchmarks.

In this Work Product Assessment, you will analyze best practices and industry standards for improving safety and quality of healthcare services. In addition, you will use patient safety centered methodologies to develop a proactive and preventative focused patient safety plan.

Competency Statement: Evaluate best practices and industry standards for patient safety and quality of healthcare services and provide recommendations for improvement.

Type of Assessment: Work Product
Prerequisites: None.

Class material information

Chapter 15, “The Role of the National Committee for Quality Assurance”
Joshi, M.S., Ransom, E.R., Nash, D.B., Ransom, S.B. (2019). The Healthcare Quality Book: Vision, Strategy, and Tools. (4th ed.). Health Administration Press, https://www.ache.org

As you view this video, consider this statement: “Every system is perfectly designed to produce exactly the results it produces.” Think about systems errors versus human factors errors and their influence on patient safety.
Walden University. (2010). Quality assessment and improvement: Patient safety [Video]. Walden University Brightspace. https://mytempo.waldenu.edu

This report provides a summary of numerous measures across the U.S. healthcare system. This global view of the national system is important for understanding patient safety and quality issues and trends at the local level. With this interactive resource, explore how the performance of the healthcare system in your state compares to the national average and review how the states compare to each other.
2020 Scorecard on State Health System Performance

Commonwealth Fund. (2020). 2020 scorecard on state health system performance. The Commonwealth Fund. https://2020scorecard.commonwealthfund.org/

This Agency for Healthcare Quality and Research (AHRQ) site contains a large selection of evidence- based technical reports and resources regarding patient safety and quality. Take time to review this site and familiarize yourself with the available resources.
Quality Improvement and Patient Safety

Agency for Healthcare Research and Quality (AHRQ). (n.d.). Tools. AHRQ. https://www.ahrq.gov/tools/index.html
Baldrige Performance Excellence Program

National Institute of Standards and Technology. (n.d.). Baldridge performance excellence program. NIST. https://www.nist.gov/baldrige
HEDIS and Performance Measurement
National Committee for Quality Assurance. (2020). HEDIS and performance measurement. NCQA. https://www.ncqa.org/hedis/

As you read, consider the differences between Failure Mode and Effect Analysis (FMEA) and Root Cause Analysis (RCA).
Patient Safety Systems

Joint Commission. (2019). Patient Safety Systems (PS). Joint Commission. https://www.jointcommission.org/-/media/tjc/documents/standards/ps-chapters/20190701_2_camh_04a_ps.pdf

This overview of FMEA will help you understand the basic concepts of this method and how they can be applied in a healthcare setting (the Healthcare Failure Mode and Effect Analysis or HFMEA). Note: Slide 19 offers a comparison of the HFMEA and root cause analysis (RCA) processes.
The Basics of Healthcare Failure Mode and Effect Analysis

U.S. Department of Veterans Affairs, National Center for Patient Safety (NCPS). (n.d.). The basics of healthcare failure mode and effect analysis. NCPS. https://www.patientsafety.va.gov/docs/hfmea/FMEA2.pdf

This website provides tools, reports, and an overview of the Failure Mode and Effect Analysis (FMEA). After reviewing the website, click the Failure Modes and Effects Analysis (FMEA) Tool, the fourth PDF in the list, for a step-by-step review of this systematic method for process evaluation. To access the actual tool, you must complete an IHI registration (no cost).

Failure Modes and Effects Analysis Tool

Institute for Healthcare Improvement (IHI). (2021). Failure Modes and Effects Analysis tool. IHI. http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx

Chapter 12 and 15 provides a systems perspective to understanding the characteristics of a safe patient care system. Additionally, they will help you understand how to incorporate process improvement tools and inclusion of patients into a patient safety program.
Chapter 12, “Creating Alignment: Quality Measures and Leadership”

Chapter 15, “The Role of the National Committee for Quality Assurance”
Joshi, M.S., Ransom, E.R., Nash, D.B., Ransom, S.B. (2019). The Healthcare Quality Book: Vision, Strategy, and Tools. (4th ed.). Health Administration Press, https://www.ache.org.

Chapter 2,”History of Performance Improvement”
McLaughlin, D. B., & Olson, J. R. (2017). Healthcare operations management (3rd ed.). Health Administration Press. https://www.ache.org.
The Quality Management Plan: A Practical, Patient-Centered Template
National Association of Community Health Centers. (2011). The quality management plan: A practical, patient-centered template.
NACHC.https://www.wvpca.org/files/NACHC%20Quality%20Management%20Plan(1).pdf
Top 10 Patient Safety Concerns 2020
ECRI. (2020). Special report: Top 10 patient safety concerns 2020. ECRI. https://assets.ecri.org/PDF/White-Papers-and-Reports/2020-Top-10-Patient-Safety-Executive-Brief.pdf

Patient Safety Primers: Systems Approach

Agency for Healthcare Research and Quality (AHRQ). (2019). Patient safety primers: Systems approach. AHRQ. https://psnet.ahrq.gov/primer/systems-approach

This resource list from the Agency for Healthcare Research and Quality (AHCRQ) provides a comprehensive collection of resources for getting started with organizational changes to improve patient safety.

Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture
Agency for Healthcare Research and Quality (AHRQ). (2019). Improving patient safety in hospitals: A resource list for users of the AHRQ Hospital Survey on Patient Safety Culture version 2.0. AHRQ. https://www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-v2-resourcelist.pdf

Evidence Brief: Implementation of High Reliability Organization Principles
Veasie, S., Peterson, K., & Bourne, D. (2019). Evidence brief: Implementation of high reliability organization principles. U.S. Department of Veteran Affairs.  https://www.ncbi.nlm.nih.gov/books/NBK542883/
Chapter 1, “Overview of Healthcare Quality” (pp. 38 – 40)

Joshi, M.S., Ransom, E.R., Nash, D.B., Ransom, S.B. (2014). The Healthcare Quality Book: Vision, Strategy, and Tools. Health Administration Press. https://www.ache.org
Measuring Patient Safety in Primary Care: The Development and Validation of the “Patient Reported Experiences and Outcomes of Safety in Primary Care” (PREOS-PC)

Ricci-Cabello, I., Avery, A. J., & Reeves, D., et al. (2016). Measuring patient safety in primary care: The development and validation of the “Patient Reported Experiences and Outcomes of Safety in Primary Care” (PREOS-PC). Annals of Family Medicine, 14(3), 253 – 261. https://www.doi.org/10.1370/afm.1935.
This presentation provides examples of different methods of quality improvements used in an actual setting.
American Society of Nephrology

American Society of Nephrology (ASN). (n.d.). ASN. https://www.asn-online.org/
How to Use Data to Improve Quality and Patient Safety

Pestotnik, S., & Lemon, V. (2019, April 30). How to use data to improve quality and patient safety. Health Catalyst. https://www.healthcatalyst.com/insights/use-data-improve-patient-safety/
Improving Healthcare Quality, Patient Outcomes, and Costs with Evidence-Based Practice

Mazurek Melnyk, B., (2020, November 16). Improving healthcare quality, patient outcomes, and costs with evidence-based practice. Nursing Centered. https://nursingcentered.sigmanursing.org/features/more-features/improving-healthcare-quality-patient-outcomes-and-costs-with-evidence-based-practice

Towards The Use of Mixed Methods Inquiry as Practice in Health Outcomes Research
Regnault, A., Willgoss, T., Barbic, S., & International Society of Quality of Life Research. (2018). Towards the use of mixed methods inquiry as practice in health outcomes research. Journal of Patient-Reported Outcomes, 2(1), 19. https://www.doi.org/10.1186/s41687-018-0043-8

Last Completed Projects