Read Chapters 5, 6, and 7 in our textbook. After reviewing this weeks 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 Adverse Event Template)
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 professionals 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 Adverse Event Template)
Once you choose your adverse event, graph the data from the chart above. 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 I were to choose medication errors, I would enter the details from column A, B, and C. Once your graph is complete, copy/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 Adverse Event Template)
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.
Fishbone (Cause and Effect) Diagram (Links to an external site.)
Flowchart (Links to an external site.)
Pareto Chart (Links to an external site.)
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 Adverse Event Template.
If you are unfamiliar with these tools, please refer to the recommended readings, specifically the Siriwardena (2009) article from Week 2, Using Quality Improvement Methods for Evaluating Health Care.
Part 4: Future Prevention (Complete Part 4 of the Adverse Event Template)
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.].)
Title of Paper
Your name
HCA375 Continuous Quality Monitoring and Accreditation
Type Instructor Name Here
Type Date
HCA375 – WEEK 4 ASSIGNMENT
PART 1 DETAIL OF THE ADVERSE EVENT CHOSEN
Refer to the instructions in the Week 4 Assignment of your online course to understand what is expected
in each row. This completed template should be between eight to ten pages in length. Include APA
citations within the description row where appropriate. List your references in APA format according to
the Ashford Writing Center guidelines on the last page of this template.
CONTENT
ADVERSE EVENT
HISTORICAL BACKGROUND
LEGAL & ACCREDITING
AGENCY REQUIREMENTS
CQI TEAM
COMMUNICATION
DESCRIPTION
OPERATIONAL OR SAFETY
PROCESSES
IMPACT OF THIS EVENT
WEEK 4 ASSIGNMENT
PART 2 – GRAPH THE DATA
You are tasked with graphing the data in Excel for your chosen event. The data is located in the
classroom under the Week 4 Assignment Directions. Make sure to use only the data for your chosen
event. The directions identify which columns of information to use depending on the chosen adverse
event. Once you complete the graph in Excel, copy/paste your graph below.
Include an analysis of the data in paragraph format.
Discuss the frequency
of the adverse event
as compared to the
increase or decrease
of patient discharges.
What is the data
telling you?
What possible factors
in your opinion could
be attributed to the
change?
WEEK 4 ASSIGNMENT
PART 3 CQI TOOL
Choose one of the CQI Tools listed below to illustrate the use of the tool with your chosen
Adverse Event.
You will be responsible for creating the CQI Tool, completing the tool, taking a screenshot, and
copying/pasting the screenshot into the space below. If you are unfamiliar with these tools,
please refer to the recommended readings, specifically the article from Week 2, which is listed
below. You can locate the article in the Ashford Library.
In addition, as a learning resource, the CQI tools listed below are hyperlinked to the Institute for
Health Care Improvement website, which discusses and illustrates examples of each type of tool.
Siriwardena, A. (2009). Using quality improvement methods for evaluating health care. Quality in
Primary Care, 17(3), 155-159. ISSN: 1479-1072 PMID: 19622265
Choose a CQI Tool that best suits your chosen Adverse Event from the following list.
o Fishbone (Cause and Effect) Diagram
o Flowchart
o Pareto Diagram
WEEK 4 ASSIGNMENT
PART 4 – FUTURE PREVENTION
APPLYING PDSA – Worksheet
PHASE
PHASE ACTIVITIES
PLAN
Problem
Objective
Team members
Communication
Data collected
Pilot phase
DO
Three possible solutions
One solution to implement
Result of pilot (create own
scenario)
Methods of communication
STUDY Summarize data
Observations and problems
Comparison of pilot plan to pilot
results
Revisions needed to meet
objective
ACT
Revised improvement plan
How to Implement the plan
hospital wide
Plan for monitoring the
improvement plan
Checks and balance
EXPLANATION
References
Excluding your textbook or course readings include at least four scholarly sources in addition to the
course text. The sources should be peer-reviewed sources; that were published within the past five years.
All references must be cited within the rows where the referenced material was used to support your
ideas. The citations and references must be in APA format per the 6th edition guidelines, which can be
found at the Ashford Writing Center.
These examples are correctly-formatted references. Note that they are in alphabetical order. You may
NOT use these examples as your sources.
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