prepare an issue analysis of an incident that occurred in a health care organization and create a leadership action plan that will help to address the specific incident but will also help to drive safety and quality improvements throughout the organization. The issue analysis and action plan together should be 8 pages.
Introduction
The quality manager at any hospital is required to address deficiencies by improving organizational culture, providing leadership oversight, and cultivating staff relationships within the organization. This role has many priorities. For example, a quality manager is tasked with analyzing any incidents that occur within the organization and creating a leadership action plan with recommended strategies and tactics to address not just the specific incident but to drive safety and quality improvement throughout the organization.
The following assessment differs from the first two assessments in that, acting as the quality manager, your focus is broader. Rather than focusing only on identifying specific actions the organization can take to remedy a particular incident that occurred, you are concentrating on what steps you will take as the quality manager to influence the organization’s leadership to cultivate a fair and just culture. What departments, leaders, and personnel will you collaborate with to improve quality for the whole organization? In this type of culture, safety is at the forefront of everyone’s job and all associates welcome the opportunity to highlight issues—without fear of reprisal—so that they can be addressed at a systemic level throughout the organization.
You may find it useful to review the short document CQI Importance and Features [PDF] as you gather your thoughts about the key elements you want to include in your assessment, Issue Analysis, and Leadership Action Plan.
Preparation
To successfully complete this assessment, use the Collaborate on Quality Template [DOC] to address the following:
• Select one of the three incidents from the Vila Health: Patient Safety simulation. These are common incidents you are likely to encounter in the health care field. You may select one of the incidents you worked with in the previous assessments or select a different one. Choose the one that holds the most interest to you. These incidents included:
o A patient identification error.
o A medication error.
o A HIPAA/privacy violation.
• Consider the following analysis questions once you have selected the incident on which you will focus:

o What information do you possess about the issue? (Note: You may not be able to answer all of these questions; just include the information you know.) Consider:
 Who was involved?
 During what process—clinical, communication, or operational—did the issue occur?
 When did the issue occur? During a particular shift? On a particular day? During peak hours? Under certain clinical circumstances?
 Where did the issue occur?
o What additional data about the incident would you like to collect and analyze?