OM004 Improving Patient safety and quality of service

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