OM004 Improving Patient safety and quality of service

©2014 Walden University 1

OM004: Improving Patient Safety and Quality of Services: Evaluate best practices and industry standards for patient safety and quality of

healthcare services and provide recommendations for improvement.

Assessment Rubric

0
Not Present

1
Needs Improvement

2
Meets Expectations

3
Exceeds Expectations

Part 1: Analysis of Patient Safety and Quality of Services in a Hospital

Sub-Competency 1: Evaluate data to identify opportunities for improvement in patient safety and quality of services.

Learning Objective 1.1:
Analyze safety and
quality measures in a
hospital.

Analysis of safety and
quality measures is
missing.

Analysis does not provide
complete and accurate
data for at least three
areas of safety and quality
measures.

Analysis does not provide
benchmark measures or
the measures are not
appropriate.

Analysis provides a
comprehensive review and
description for at least
three areas of safety and
quality measures.

Analysis provides
appropriate benchmark
measures.

Demonstrates the same
level of achievement as
“2” plus the following:

Analysis includes the last
2–3 years’ worth of data
for the purpose of
identifying trends.

Learning Objective 1.2:
Summarize a process
for accessing data.

Summary of a process for
accessing data is missing.

Response insufficiently or
inaccurately summarizes
websites that provide data
used in the
recommendation.

Response identifies and
summarizes at least two
websites that provide the
data used in the
recommendation.

Explain any limitations in
available data.

Demonstrates the same
level of achievement as
“2” plus the following:

Response summarizes
which sites provided data
in a more useful
(consumable, easy to
navigate, easy to
understand) manner and
explains why.

©2014 Walden University 2

0
Not Present
1
Needs Improvement
2
Meets Expectations
3
Exceeds Expectations

PS006: Information Literacy: Apply appropriate strategies to identify relevant and credible information and data in order to effectively
analyze issues and make decisions.

Learning Objective
PS 6.1:
Identify credible
sources.

Identification of credible
sources is missing.

Some sources are credible,
appropriate, and relevant
to the topic.

Most sources are credible,
appropriate, and relevant
to the topic.

All resources are credible,
appropriate, and relevant
to the topic.

Learning Objective
PS 6.2:
Analyze findings from
relevant sources.

Analysis of findings from
relevant sources is missing.

Analysis superficially
reflects relevance of
findings to the identified
problem, issue, or
purpose.

Analysis clearly reflects
relevance of findings to
the identified problem,
issue, or purpose.

Analysis clearly reflects
relevance of findings to
the identified problem,
issue, or purpose, and
synthesizes findings to
generate new insights.

Part 2: Failure Mode and Effects Analysis

Sub-Competency 2: Apply the Failure Mode and Effects Analysis method to identify and prioritize possible failure points.

Learning Objective2.1:
Apply a Failure Mode
Effects Analysis (FMEA)
to target areas for
improvement.

Application of FMEA to
target areas for
improvement is missing.

FMEA does not clearly
identify and describes a
specific issue or process.

FMEA is incomplete and
does not provide
suggestions for patient
safety and quality
improvement.

FMEA has a clearly defined
target issue or process.

FMEA is complete and
identifies clear
opportunities for
increasing quality of care
or preventing patient
safety incidents in three
distinct areas.

Demonstrates the same
level of achievement as
“2” plus the following:

FMEA includes potential
unintended consequences
from a systems
perspective.

Part 3: Patient Safety Plan

Sub-Competency 3: Design a patient safety plan.

Learning Objective 3.1:
Design an actionable
patient safety plan.

Patient safety plan is
missing.

Patient safety plan is
incomplete or does not
include the results from a
FMEA.

Patient safety plan is
comprehensive and covers
three areas of focus.

Demonstrates the same
level of achievement as
“2” plus the following:

©2014 Walden University 3

0
Not Present
1
Needs Improvement
2
Meets Expectations
3
Exceeds Expectations

Patient safety plan
incorporates the
information gathered
during the FMEA.

Patient safety plan is
actionable and describes
specific steps.

Patient safety plan
addresses who will be
responsible for acting on
the recommendations. In
addition, the plan speaks
to potential costs of
implementation.

Sub-Competency 4: Create an evaluation method to measure the success of a patient safety plan.

Learning Objective 4.1:
Describe an
assessment measure to
determine if a patient
safety plan is
successful.

Description of an
assessment measure to
determine if a patient
safety plan is successful is
missing.

Evaluation method is
vague and does not show
how the patient safety
plan is successful.

Evaluation method is
realistic and provides
measurable criteria to
evaluate success.

Evaluation can accurately
determine if the patient
safety plan is successful.

Demonstrates the same
level of achievement as
“2” plus the following:

Evaluation method
provides a detailed
description of data
collection and quantitative
analysis methods that will
be used.

PS001: Written Communication: Demonstrate graduate-level writing skills.

Learning Objective
PS 1.1:
Use proper grammar,
spelling, and
mechanics.

Multiple major and minor
errors in grammar,
spelling, and/or mechanics
are highly distracting and
seriously impact
readability.

Multiple minor errors in
grammar, spelling, and/or
mechanics are distracting
and negatively impact
readability.

Writing reflects competent
use of standard edited
American English.

Errors in grammar,
spelling, and/or mechanics
do not negatively impact
readability.

Grammar, spelling, and
mechanics reflect a high
level of accuracy in
standard American English
and enhance readability.

Learning Objective
PS 1.2:
Organize writing to

Writing is poorly organized
and incoherent.
Introductions, transitions,

Writing is loosely
organized. Limited use of
introductions, transitions,

Writing is generally well-
organized. Introductions,
transitions, and

Writing is consistently
well-organized.
Introductions, transitions,

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enhance clarity.

and conclusions are
missing or inappropriate.

and conclusions provides
partial continuity.

conclusions provide
continuity and a logical
progression of ideas.

and conclusions are used
effectively to enhance
clarity, cohesion, and flow.

Learning Objective
PS 1.3:
Apply APA style to
written work.

APA conventions are not
applied.

APA conventions for
attribution of sources,
structure, formatting, etc.,
are applied inconsistently.

APA conventions for
attribution of sources,
structure, formatting, etc.,
are generally applied
correctly in most
instances. Sources are
generally cited
appropriately and
accurately.

APA conventions for
attribution of sources,
structure, formatting, etc.,
are applied correctly and
consistently throughout
the paper. Sources are
consistently cited
appropriately and
accurately.

Learning Objective
PS 1.4:
Use appropriate
vocabulary and tone
for the audience and
purpose.

Vocabulary and tone are
inappropriate and
negatively impact clarity of
concepts to be conveyed.

Vocabulary and tone have
limited relevance to the
audience.

Vocabulary and tone are
generally appropriate for
the audience and support
communication of key
concepts.

Vocabulary and tone are
consistently tailored to the
audience and effectively
and directly support
communication of key
concepts.

PS005: Critical Thinking and Problem Solving: Use critical-thinking and problem-solving skills to analyze professional issues and inform best
practice.

Learning Objective
PS 5.1:
Analyze assumptions
and fallacies.

Analysis of assumptions is
missing.

Response is weak in
assessing the
reasonableness of
assumptions in a given
argument.

Response does not
adequately identify and
discuss the implications of
fallacies or logical
weaknesses in a given
argument.

Response generally
assesses the
reasonableness of
assumptions in a given
argument.

Response identifies and
discusses the implications
of fallacies and/or logical
weaknesses in a given
argument.

Response clearly and
comprehensively assesses
the reasonableness of
assumptions in a given
argument.

Response provides a
detailed and compelling
analysis of implications of
fallacies and logical
weaknesses in a given
argument.

Learning Objective Assumptions are missing. Response does not Response presents and Response justifies the

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PS 5.2:
Generate reasonable
and appropriate
assumptions.

adequately present and
discuss key assumptions in
an original argument.

discusses key assumptions
in an original argument.

reasonableness and need
for assumptions in an
original argument.

Learning Objective
PS 5.3:
Assess multiple
perspectives and
alternatives.

Assessment of multiple
perspectives is missing.

Response does not identify
nor adequately consider
multiple perspectives or
alternatives.

Response identifies and
considers multiple
perspectives and
alternatives.

Response justifies
selection of chosen
alternative relative to
others.

Learning Objective
PS 5.4:
Use problem-solving
skills.

Problems and solutions are
not identified.

Response presents
solutions, but they are
ineffective in addressing
the specific problem.

Response presents
solutions that are practical
and work in addressing the
specific problem.

Response presents
compelling supporting
arguments for proposed
solutions.

Part 1: 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 Score; 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 2- to 3-page analysis:

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

· Describe the search procedures you used to access the data.

Part 2: Failure Mode and Effects Analysis

Use the FMEA (Failure Mode and Effects Analysis) Template from the Institute of Healthcare Improvement (Sub-competency 2 resources). To get to the actual tool, you must complete an IHI registration (no cost). Use the tool to look for a weak link in the quality chain. Template 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.

Part 3: Patient Safety Program

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. Create a 5- to 7-page patient safety program focusing on that one area.

· Design a patient safety plan to address three areas of focus from the results of the FMEA.

· Describe an assessment measure to determine if the patient safety plan is successful