Assessment 1 Instructions: Adverse Event or Near-Miss Analysis

Prepare an analysis (5-7 pages) of an adverse event or a near miss from your professional nursing experience and outline a QI initiative that would address it.

Introduction

Health care organizations strive to create a culture of safety. Despite technological advances, quality care initiatives, oversight, ongoing education and training, legislation, and regulations, medical errors continue to be made. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation. Many errors are attributable to ineffective interprofessional communication.

Overview

The goal of this assessment is to allow you to focus on a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities and to propose a QI initiative to prevent future incidents. It will give you the chance to develop your analytical skills in the problem-solving contexts you likely find yourself in as a health care professional.

Health care organizations strive for a culture of safety. Yet, despite technological advances, quality care initiatives, oversight, ongoing education and training, laws, legislation, and regulations, medical errors continue to occur. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation.

Historically, medical errors were reported and analyzed in hindsight. Today, QI initiatives attempt to be proactive, which contributes to the amount of attention paid to adverse events and near misses. Backed up by new technologies and reporting metrics, adverse events and near misses can provide insight into potential ways to improve care delivery and ensure patient safety.

For clarification, the National Quality Forum (n.d.) defines the following:

Adverse event: An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.

Near miss: An event or a situation that did not produce patient harm, but only because of intervening factors, such as patient health or timely intervention.

Instructions

Prepare a comprehensive analysis of an adverse event or a near miss from your professional nursing experience that you or a peer experienced. Provide an analysis of the impact of the same type of adverse event or near miss in other facilities. How was it managed, who was involved, and how was it resolved? Be sure to:

Analyze the implications of the adverse event or near miss for all stakeholders.

Analyze the sequence of events, missed steps, or protocol deviations related to the adverse event or near miss using a root cause analysis.

Evaluate QI actions or technologies related to the event that are required to reduce risk and increase patient safety. 

Evaluate how other institutions integrated solutions to prevent these types of events.

Incorporate relevant metrics of the adverse event or near miss to support need for improvement.

Outline a QI initiative to prevent a future adverse event or near miss.

Ensure your analysis conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Be sure your analysis addresses all of the above points. You may also want to read the Adverse Event or Near Miss Analysis Scoring Guide to better understand the performance levels that relate to each grading criterion. Additionally, be sure to review the Guiding Questions: Adverse Event or Near Miss Analysis [DOCX] document for additional clarification about things to consider when creating your assessment.

Additional Requirements

Your assessment should also meet the following requirements:

Length of submission: A minimum of five but no more than seven double-spaced, typed pages, not including the title page or References section.

Number of references: Cite a minimum of three sources of scholarly or professional evidence that support your evaluation, recommendations, and plans. Current source material is defined as no older than five years unless it is a seminal work. Review the Nursing Master's Program (MSN) Library Guide for guidance.

APA formatting: Resources and citations are formatted according to current APA style. Review the Evidence and APA section of the Writing Center for guidance.

Assessment 2: Quality Improvement Initiative Evaluation

Prepare an evaluation (5-7 pages) of an existing QI initiative to determine if the initiative is effective.

Introduction

Too often, discussions about quality health care, care costs, and outcome measures take place in isolation—various groups talking among themselves about results and enhancements. Nurses are critical to the delivery of high-quality, efficient health care. As a result, they must develop their skills in reviewing and evaluating performance reports. They also need to be able to communicate outcome measures related to quality initiatives effectively. Patient safety and positive institutional health care outcomes mandate collaboration among nursing staff members to ensure the integration of their perspectives in all quality care initiatives.

Overview

In the first assessment, you analyzed an adverse event or a near miss, and outlined a QI initiative to address it. This assessment will give you practice and the confidence to evaluate a quality care initiative in much the same way you might in your health care setting to help determine if the initiative is effective.

Too often, discussions about quality health care, care costs, and outcome measures take place in isolation—each group talking among themselves about results and enhancements. Because nurses are critical to the delivery of high-quality, efficient health care, it is essential that they develop the proficiency to review, evaluate performance reports, and be able to effectively communicate outcome measures related to quality initiatives. The nursing staff's perspective and the need to collaborate on quality care initiatives are fundamental to patient safety and positive institutional health care outcomes.

Instructions

Imagine you have been asked to prepare and deliver an analysis of an existing QI initiative at your workplace. The QI initiative you choose to analyze should be related to a specific disease, condition, or public health issue of personal or professional interest to you, or you may use the hospice information provided in the Vila Health: Data Analysis activity in this assessment. The purpose of the report is to assess whether the specific quality indicators point to improved patient safety, quality of care, cost and efficiency goals, and other desired metrics. Your target audience is nurses and other health professionals with specializations or interest in your chosen condition, disease, or public health issue.

In your report, you will:

Analyze a current QI initiative in a health care setting. 

Identify what prompted implementation of the QI initiative.

Evaluate problems that arose during the initiative or problems that were not addressed.

Evaluate the success of a current QI initiative through recognized benchmarks and outcome measures as required to meet national, state, or accreditation requirements. 

Identify the core performance measurements related to successful treatment or management of the condition.

Evaluate the impact of the quality indicators on the health care facility.

Incorporate interprofessional perspectives related to the success of actions used in the QI initiative as they relate to functionality and outcomes.

Recommend additional indicators and protocols to improve and expand outcomes of a current quality initiative.

Ensure your analysis conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Be sure to address all of the bullet points. You may also want to read the Quality Improvement Initiative Evaluation Scoring Guide to better understand the performance levels that relate to each grading criterion. Additionally, be sure to review the Guiding Questions: Quality Improvement Initiative Evaluation [DOCX]document for additional clarification about things to consider when creating your assessment.

Additional Requirements

Your assessment should also meet the following requirements:

Length of submission: A minimum of five but no more than seven double-spaced, typed pages, not including the title page and References section.

Number of references: Cite a minimum of four sources of scholarly or professional evidence that support your evaluation, recommendations, and plans. Current source material is defined as no older than five years unless it is a seminal work. Review the Nursing Master's Program (MSN) Library Guidefor guidance.

APA formatting: Resources and citations are formatted according to current APA style. Review the Evidence and APA section of the Writing Center for guidance.

Assessment 3: Data Analysis and Quality Improvement Initiative Proposal

Make a quality initiative proposal (7-10 PowerPoint slides) through a presentation, interpreting and communicating dashboard data to support the proposal.

Introduction

Health care providers are perpetually striving to improve care quality and patient safety. To accomplish enhanced care, outcomes need to be measured. Next, data measures must be validated. Measurement and validation of information support performance improvement. Health care providers must focus attention on evidence-based best practices to improve patient outcomes.

Health informatics, along with new and improved technologies and procedures, are at the core of all quality improvement initiatives. Data analysis begins with provider documentation, researched process improvement models, and recognized quality benchmarks. All of these items work together to improve patient outcomes. Professional nurses must be able to interpret and communicate dashboard information that displays critical care metrics and outcomes along with data collected from the care delivery process.

Overview

A basic principle of quality measurement is: If you can't measure it, you can't improve it.

–Agency for Healthcare Research and Quality (2021)

In the previous assessment, you analyzed the effectiveness of an existing quality initiative. Now that you've done that, this assessment gives you experience interpreting and communicating dashboard data for the purpose of making a quality initiative proposal of your own. And you'll make your proposal through a PowerPoint presentation, including using speaker notes in the Notes section of the slides, much like you might in your health care setting.

Health care providers are on an endless quest to improve both care quality and patient safety. This unwavering commitment requires hospitals and care givers to increase their attention and adherence to treatment protocols to improve patient outcomes. Health informatics, along with new and improved technologies and procedures, are at the core of virtually all QI initiatives. The data gathered by providers, along with process improvement models and recognized quality benchmarks, are all part of a collaborative, continuing effort. As such, it is essential that professional nurses are able to correctly interpret and effectively communicate information revealed on dashboards that display critical care metrics.

Instructions

In this assessment, you will make a QI initiative proposal based on a health issue of professional interest to you. This proposal will be based on an analysis of dashboard metrics from a health care facility. You have one of two options:

Option 1

If you have access to dashboard metrics related to a QI initiative proposal of interest to you:

Analyze data from the health care facility to identify a health care issue or an area of concern. You will need access to reports and data related to care quality and patient safety. If you work in a hospital setting, contact the quality management department to obtain the data you need. 

You will need to identify basic information about the health care setting, size, and specific type of care delivery related to the topic that you identify. You are expected to abide by standards for compliance with the Health Insurance Portability and Accountability Act (HIPAA).

Option 2

If you do not have access to a dashboard or metrics related to a QI initiative proposal:

You may use the hospital data set provided in the Vila Health: Data Analysis media piece to identify a health care issue or an area of concern.

You will follow the same instructions and provide the same deliverables as your peers who select Option 1.

Complete the following steps for your proposal:

Analyze data to identify a health care issue or an area of concern as it relates to a state, national, or accreditation benchmark requirement relevant to your professional setting. 

Evaluate the quality of the data.

Outline a QI initiative proposal based on the selected health issue or area of concern and supporting data analysis to improve identified dashboard metric. The interactive activity Designing a Quality Improvement Initiative can get you going on the first steps of a QI process and your assessment. 

Identify the target areas of improvement and outcome measures.

Include the QI model that will be utilized.

Specify evidence-based strategies that will be utilized.

Integrate interprofessional perspectives and actions to lead quality improvements in patient safety, cost-effectiveness, and work-life quality. 

Specify roles and responsibilities.

Apply effective collaboration strategies to promote QI of interprofessional care. 

Include specific communication tools.

Deliver a persuasive, coherent, and effective audiovisual presentation. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.

Be sure that your proposal, at minimum, addresses each of the bullet points. You may also want to read the Data Analysis and Quality Improvement Initiative Proposal Scoring Guide to better understand the performance levels that relate to each grading criterion. Additionally, be sure to review the Guiding Questions: Data Analysis and Quality Improvement Initiative Proposal [DOCX] document for additional clarification about things to consider when creating your assessment.

RECORDING YOUR PRESENTATION

Before starting to record your presentation make sure you have:

Set up and tested your microphone and headset using the installation instructions provided by the manufacturer. You only need to use the headset if your audio is not clear or high quality when captured by the microphone.

Practice using the equipment to ensure the audio quality is sufficient.

Consult Using Kaltura for guidance on how to record your presentation and upload it in the courseroom.

Microsoft PowerPoint also allows you to record your narration with your slides. If you choose this option, simply submit your presentation to the appropriate area of the courseroom. Your narration will be included with your slides.

Remember to practice delivering and recording your presentation multiple times to ensure effective delivery.

Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact Disability Services at DisabilityServices@Capella.edu to request accommodations.

Additional Requirements

Your assessment should also meet the following requirements:

Length of submission: 7–10 PowerPoint slides, with speaker notes, not including title slide and attached reference list. Balance text with visuals. Avoid text-heavy slides. Use speaker's notes for additional content.

Length of presentation: No more than 10 minutes.

Number of references: Cite a minimum of five sources (no older than seven years, unless a seminal work) of scholarly or professional evidence to support your evaluation, recommendations, and plans. Review the Nursing Master's Program (MSN) Library Guide for guidance.

APA formatting: Resources and citations are formatted according to current APA style. Review the Evidence and APA section of the Writing Center for guidance.