Assignment: Quality Monitoring and Accreditation Worksheet

Read Chapters 5, 6, and 7 in our textbook. After reviewing this week’s required reading, consider the following scenario. You are the lead of the risk management team that has been assigned to evaluate an incident that has occurred. You will prepare a report for the CEO of the hospital that includes all system failures that contributed to the adverse event as well as create a CQI tool (i.e., Pareto, Fishbone, or Flowchart). You are required to download and use the Adverse Event Template document to complete the assignment. Note: If you have responded substantively to each of the content items within the assignment document and included your graph of the data as well as the CQI tool illustration, the template document should be between eight to 10 pages.

Part 1: Description of Adverse Event (Complete Part 1 of the )

Medication error

Patient falls

Post-operative hemorrhage

Completing the template:

Adverse Event

Identify the chosen event.

Create a scenario based on your chosen event.

Discuss the incident and what happened.

Identify the health care professionals involved.

Explain the health care professional’s role in the incident.

• Historical Background
• Discuss the prevalence of the adverse event including historical information (i.e., how often this type of event occurs, and prevention methods used by the industry).
• Legal and Accrediting Agency Requirements

Address legal ramifications and accreditation agency requirements regarding the adverse event.

CQI Team and Communication

• Identify the CQI team members. Based on the members you chose:

Explain how their role within the hospital would benefit your team in identifying and analyzing the cause of the adverse event.

• Discuss issues that could arise between the team members when attempting to develop an improvement plan.
• Describe the steps you would take as the CQI team lead to make sure that everyone is able to communicate their opinions and recommendations.
• Describe barriers or conflicts that could occur within your team regarding effective communication.
• Operational or Safety Processes
• Discuss at least two operational and safety processes that you would recommend to the team to avoid future events from occurring.
• Explain the rationale for your recommendations.

Impact of Event

• Discuss the impact on the hospital if the events continue to occur.
• Discuss the impact to the patients if the events continue to occur.

Note: The number of beds and operating rooms increased from 2017 to 2018.

• Part 2: Graph the Data (Complete Part 2 of the )Once you choose your adverse event, graph the data from the  You will graph Column A and B against the chosen event (i.e., number of medication errors, number of patient falls, or number of post-operative hemorrhages). For example, if you were to choose medication errors, you would enter the details from column A, B, and C. Once your graph is complete, right click over the graph to copy it, then paste it in the space indicated within the template.
• Include an analysis of the data within the spaces indicated in the template:

Discuss the frequency of the adverse event as compared to the increase or decrease of patient discharges.

• Analyze the data (what is the data telling you?).

Identify the possible factors, in your opinion, that could be attributed to the change.

• Part 3: Create the CQI tool (Complete Part 3 of the )
• Choose one of the CQI Tools listed below that best aligns with your chosen Adverse Event. Each of the tools listed below are hyperlinked to the Institute for Health Care Improvement website, which discusses and illustrates examples of each type of tool.

Next, you will be responsible for creating the CQI Tool, completing the tool, taking a screenshot, and copying/pasting the screenshot into the space indicated within the 

• Part 4: Future Prevention (Complete Part 4 of the )
• After describing the event in Part 1, using a Graph in Part 2 and CQI tool in Part 3, you will apply the PDSA model in Part 4 to summarize the process and steps that your team would recommend to the CEO to prevent this adverse event from reoccurring.
• Respond to the items in Part 4 of the template by including the following:

Plan

• Identify the problem that caused the adverse event/
• Identify your objective.

Identify the team members that will assist in the development of a plan for improvement.

Describe how you would communicate the plan to the stakeholders.

Discuss the reasons for collecting the data associated with the chosen scenario.

Identify where you will pilot the new plan of action.

Identify who, what, or why for your pilot of the improvement plan. (When you implement any new plan of action in a hospital setting, you will do a pilot of the new plan in a small, targeted area or department. For example, if you chose medication errors, a group of patients will be on the same floor [e.g., medical unit, cardiac unit, etc.]. If you chose patient falls, the patients will have the same diagnosis [e.g., hip replacement, etc.]. If you chose post-operative hemorrhage, the patients will have the same type of surgical procedure [e.g., abdominal surgeries, etc.].)

Do

Develop three possible solutions to the problem.

Select one of the possible solutions to implement in the pilot phase.

Discuss the result of the pilot (create your own scenario).

Explain in detail the methods utilized to communicate the improvement process to the area chosen for the pilot phase.

Study

Summarize the data collected.

• Discuss how you would measure whether the pilot solution was effective.

List observations.

• Discuss any problems that may have occurred in your scenario.
• Discuss any communication issues.
• Compare your objective in the Plan phase to that of the actual pilot result.

Discuss what needs to be revised in your improvement plan to meet your objective.

Act

Discuss your revised plan.

Describe how you are going to implement the plan hospital-wide.

Describe how you will continually monitor the improvement plan to ensure sustained success.

• Determine if one of the steps you are recommending would require a check and balance step.

Discuss why it is necessary. (It is important to keep in mind that some processes require a system of checks and balances.)

Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

• Your response needs to be a minimum of 150 words (not including your list of references)
• There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
• Include in-text citations in your response
• Do not include quotes—instead summarize and paraphrase the information
• Follow APA-7th edition
• Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

• A minimum of 6 responses per week, on at least 3 days of the week.
• Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
• Each response needs to be at least 75 words in length (does not include your list of references)
• Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
• Follow APA 7th edition
• Points will be deducted if the above is not followed

• Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
• Here are some helpful links
• The is a great resource