Safety score improvement plan paper



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Safety Score Improvement Plan for TrueWill General Hospital

Learner’s Name

Capella University

Organizational and System Management for Quality Outcomes

Safety Score Improvement Plan

May, 2017


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Safety Score Improvement Plan for TrueWill General Hospital

Nursing professionals are key players in maintaining a culture of quality care and patient

safety in a health care environment. Their role in addressing specific patient safety issues will be

discussed using the example of TrueWill General Hospital (TGH), a 1,500-bed multispecialty

hospital in the United States. The hospital regularly reports its performance data to the Hospital

Safety Score, a nongovernmental organization that ranks hospitals on their safety rate.

The safety score for the orthopedic inpatient unit of TGH has alarmingly increased

because of the number of patient injuries resulting from falls. The negative score can affect the

image of the hospital, because patient falls are preventable hospital-acquired conditions. The

nurse manager of the unit has been advised by the hospital’s patient safety office to identify the

cause of the problem, determine an evidence-based safety score improvement plan, and devise

measurable long-term solutions for the safety issue.

Factors behind the Patient Safety Issue

Patient falls are one of the most reported patient safety incidents in health care practice.

According to the American Nurses Association (n.d.), it is a serious problem in nursing and

health care; as injuries resulting from falls can lead to permanent loss of function of certain body

parts or even death. According to systems theory, adverse events such as patient falls are related

to the quality of care provided by health care professionals at the front line of operations such as

nursing professionals (Lawton, Carruthers, Gardner, Wright, & McEachan, 2012).

Health care experts have relied on systems theory and systems thinking perspectives to

analyze the incidence of safety issues as a nursing challenge. The theory states that problems in

any part of a system, such as the nursing department in a hospital, will affect the functioning of

Comment [A1]: Yes, patient falls and how can lead to adverse effects,

even death.


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the hospital as a whole. Therefore, larger organizational systems should be taken into

consideration while implementing changes in nursing profession to improve safety issues.

Influence of Leadership in Changes for Safety

Nurse leaders at TGH are an important systems factor in driving changes at the

organizational and clinical level. The importance of leadership in achieving better patient

outcomes or patient experiences was explored in a study of leadership practices and styles

(Wong, Cummings, & Ducharme, 2013). The study showed that relational leadership styles,

which focused on people and relations, improved patient outcomes because nurse leaders were

able to assess patients’ needs better and coordinate staff and resources accordingly (Wong et al.,


TGH nurse leaders can use relational leadership styles to analyze the systems effect of

safety issues on patients and nursing professionals. The leadership style can improve job

satisfaction among nursing professionals by better managing staff and can enhance patient safety

and satisfaction by providing quality care. Relational nurse leaders are also able to effectively

use systems theory to analyze organizational policies and procedures that impact patients directly

and affect the way nursing professionals deliver care.

The Effects of Policies and Procedures on Safety Issues

Policies and procedures govern every aspect of nursing such as management of staff,

modes of health care delivery, and fiscal and material resources. When applied to policies and

procedures governing staff management, systems theory helps nurse leaders assess the

competencies of their nursing professionals, plan staff schedules to prevent work overload, hire

more nurses to address shortages, and introduce strategies to retain current nurses.

Comment [A2]: Yes, patient centered care.


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The dynamic systems model, a systems-theory-based model, can help nurse leaders

monitor and reassess those policies (Morath, 2011). It promotes a transparent health care system

where nurses are trained to (a) provide transparent care, (b) anticipate and pullback from risky

practice, (c) work with other health care professionals, (d) monitor peers, and (e) be innovative

and open to new technology that tests and studies safety practices. The model requires nurse

leaders to research potential safety issues and gather evidence about those issues before

implementing specific changes.

Recommendations to Ensure Patient Safety

Introducing changes for patient safety starts with collecting information, which will

ensure an evidence-based approach to solving problems. The data collected will help devise a

safety improvement plan. A structured approach to organizational change is important if the plan

is to be properly implemented.

The root cause analysis (RCA) is a systematic analysis of the common causes of safety

issues. The RCA also devises strategies to prevent future safety incidents. Based on systems

theory, the techniques of the RCA move beyond individual blame for clinical errors and examine

the organizational factors that contribute to the errors (Huber, 2017; Dolansky & Moore, 2013).

According to Dolansky and Moore, all nursing professionals must know how to conduct

the RCA as it teaches them about systems theory. However, there are difficulties in obtaining

information for the RCA. Teams that conduct RCAs often overlook important evidence in the

care process in their hurry to complete the analysis before the stipulated 45 days set by the Joint

Commission (Wocher, 2015). The lack of information can impede strategies for implementing

evidence-based changes in safety.

Evidence-based Strategy to Improve Patient Safety

Comment [A3]: The model promotes…

Comment [A4]: Reference?

Comment [A5]: Good inclusion of QSEN, to improve include limitations

of the strategy.


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Competency development integrated into staff management is a proven strategy in

improving patient outcomes. One evidence-based education plan that can be adapted to clinical

practice is the Quality and Safety Education in Nursing (QSEN) initiative. Funded by the Robert

Wood Johnson Foundation, the competencies of the QSEN integrate quality improvement and

safety management into nursing education (Dolansky & Moore, 2013).

With the QSEN’s background in systems theory, nursing professionals can apply it at the

individual and organizational levels of care. The six competencies of the QSEN are as follows:

(a) patient-centered care, (b) evidence-based practice, (c) teamwork and collaboration, (d) safety,

(e) quality improvement, and (f) informatics (Dolansky & Moore, 2013). Nursing professionals

who develop these competencies are better able to deliver safe care and solve safety issues.

However, there are limitations to the QSEN strategy. The QSEN is more than a decade

old and has not been updated. Despite these difficulties, the QSEN competencies have become a

key component of quality care and patient safety.

Plan to Implement Safety Recommendation and Monitor Outcomes

The education department teaches staff to think like systems thinkers and develop

personal mastery over the profession and system (Burke & Hellwig, 2011). The education

department at TGH could integrate QSEN competencies into education programs using a

framework for organizational learning called the Baldrige framework. A system of continuous

quality improvement, the Baldrige framework explains seven criteria that are indicators of

quality for organizational learning programs: (a) leadership; (b) strategic planning; (c) focus on

patients, other customers, and markets; (d) measurement, analysis, and knowledge management;

(e) workforce focus; (f) process management; and (g) organizational performance results (Burke

& Hellwig, 2011; Huber, 2017). Educational outcomes can be monitored at two levels: (a) the

Comment [A6]: Need to elaborate a little more about accountability of



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systems level where organizational performance is reviewed through patient and customer

satisfaction surveys, scorecards, and human resources indicators; and (b) at the departmental

level through pre- and post-testing of nursing professionals, course evaluations, further training

of select nursing professionals, and assessments.

The improvement of safety standards at TGH starts with developing the competency of

its nurse leaders and nursing professionals. Because nursing professionals are at the front lines of

care delivery, nurse educators should tailor programs, content, and goals to suit the unique needs

of the nursing profession.


Patient safety issues such as patient falls are commonplace in a health care organization.

Health care professionals must develop the foresight and strategic thinking to identify patient

safety issues early and have solutions at the ready. The example of TGH shows the importance of

preemptively addressing safety issues in nursing instead of letting them fester over time and

affect organizational performance. TrueWill General Hospital and its leadership should take an

active interest in developing nursing competencies continuously, focusing on quality and safety

education. Embedding these ideas into the safety score improvement plan will create a lasting

culture of quality care and patient safety. These are the standards that define the organization’s

image in health care.

Comment [A7]: Good!


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American Nurses Association. (n.d.). Patient Falls. Retrieved from

Burke, K. M., & Hellwig, S. D. (2011). Education in high-performing hospitals: Using the

Baldrige framework to demonstrate positive outcomes. The Journal of Continuing

Education in Nursing, 42(7), 299–305. https://dx.doi/10.3928/00220124-20110103-01

Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education for nurses (QSEN): The

key is systems thinking. OJIN: The Online Journal of Issues in Nursing, 18(3).


Huber, D. L. (2017). Leadership and nursing care management (6th ed.) Philadelphia: W.B.


Lawton, R., Carruthers, S., Gardner, P., Wright, J., & McEachan, R. R. C. (2012). Identifying the

latent failures underpinning medication administration errors: An exploratory

study. Health Services Research, 47(4), 1437–1459.


Morath, J. (2011). Nurses create a culture of patient safety: It takes more than projects. Online

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The Joint Commission. (2015). Root cause analysis in health care: Tools and techniques (5th

ed.). Retrieved from

Tomlinson, J. (2012). Exploration of transformational and distributed leadership. Nursing

Management, 19(4), 30–34.


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Wocher, J. C. (2015). The importance of a rigorous root cause analysis (RCA) for healthcare

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leadership and patient outcomes: A systematic review update. Journal of nursing

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