Safety Score Improvement Plan for TrueWill General Hospital
Running head: SAFETY SCORE IMPROVEMENT PLAN 1
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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
SAFETY SCORE IMPROVEMENT PLAN 2
Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.
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.
SAFETY SCORE IMPROVEMENT PLAN 3
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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.,
2013).
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.
SAFETY SCORE IMPROVEMENT PLAN 4
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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.
SAFETY SCORE IMPROVEMENT PLAN 5
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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
staff.
SAFETY SCORE IMPROVEMENT PLAN 6
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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.
Conclusion
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!
SAFETY SCORE IMPROVEMENT PLAN 7
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References
American Nurses Association. (n.d.). Patient Falls. Retrieved from
http://ana.nursingworld.org/qualitynetwork/patientfallsreduction.pdf
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).
https://dx.doi/10.3912/OJIN.Vol18No03Man01
Huber, D. L. (2017). Leadership and nursing care management (6th ed.) Philadelphia: W.B.
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Lawton, R., Carruthers, S., Gardner, P., Wright, J., & McEachan, R. R. C. (2012). Identifying the
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Morath, J. (2011). Nurses create a culture of patient safety: It takes more than projects. Online
journal of issues in nursing, 16(3). https://dx.doi/10.3912/OJIN.Vol16No03Man02
The Joint Commission. (2015). Root cause analysis in health care: Tools and techniques (5th
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Tomlinson, J. (2012). Exploration of transformational and distributed leadership. Nursing
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SAFETY SCORE IMPROVEMENT PLAN 8
Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.
Wocher, J. C. (2015). The importance of a rigorous root cause analysis (RCA) for healthcare
sentinel events. Japan-hospitals: The Journal of the Japan Hospital Association, 34, 23–
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Wong, C. A., Cummings, G. G., & Ducharme, L. (2013). The relationship between nursing
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