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OM004: Improving Patient Safety and Quality Services: Evaluate best practices and industry standards for patient safety and quality of healthcare services and provide recommendations for improvement. Assessment Rubric Rubric Criteria Needs Improvement Meets Expectations Exceeds Expectations Part One: Safety and Quality Measure Analysis Learning Objective 1.1: Analyze safety and quality measures in a hospital. Learning Objective 1.2: Describe a process for accessing data. Analysis does not provide or provides incomplete and/or inaccurate data for at least three areas of safety and quality measures. Or provides data for less than three areas of safety and quality measures. Analysis does not provide benchmark measures, or the measures are not appropriate. Analysis does not describe, describes fewer than two, or insufficiently or inaccurately describes two websites that provide data used in the recommendation. Analysis does not explain, insufficiently or inaccurately explains any limitations in available data. Rubric Criteria © 2021 Walden University Needs Improvement Analysis provides a comprehensive review and description for at least three areas of safety and quality measures. Analysis provides appropriate benchmark measures. Analysis sufficiently and accurately describes at least two websites that provide the data used in the recommendation. Analysis explains any limitations in available data. Meets Expectations Analysis demonstrates the same level of achievement as “Meets,” plus the following: Analysis includes the last 2–3 years’ worth of data for the purpose of identifying trends. Analysis demonstrates the same level of achievement as “Meets,” plus the following: Analysis explains which sites provided data in a more useful (consumable, easy to navigate, easy to understand) manner and explains why. Exceeds Expectations 1 Part Two: Failure Mode Effects Analysis Learning FMEA is missing or does not clearly Objective 2.1: identify and describe a specific issue or process. Apply a Failure Mode Effects FMEA is incomplete and does not Analysis (FMEA) to provide suggestions for patient target areas for safety and quality improvement. improvement. Rubric Criteria Needs Improvement Part Three: Patient Safety Plan Proposal Learning Proposal does not describe, vaguely Objective 3.1: or inaccurately describes a safety plan that covers fewer than three Design an areas of focus or does not include actionable patient the results from a FMEA. safety plan. Patient safety plan is not actionable and does not describe specific steps. Learning Objective 3.2: Describe an evaluation method © 2021 Walden University Proposal does not describe, vaguely or inaccurately describes an evaluation method to assess whether the patient safety plan is successful. FMEA has a clearly defined target issue or process. FMEA is complete and identifies clear opportunities for increasing quality of care or preventing patient safety incidents in three distinct areas. Meets Expectations Proposal clearly and accurately describes a comprehensive patient safety plan that covers three areas of focus. Patient safety plan incorporates the information gathered during the FMEA. Patient safety plan is actionable and describes specific steps. Proposal clearly and accurately describes an evaluation method to assess whether the patient safety plan is successful. FMEA demonstrates the same level of achievement as “Meets,” plus the following: FMEA includes potential unintended consequences from a systems perspective. Exceeds Expectations Proposal demonstrates the same level of achievement as “Meets,” plus the following: Proposal addresses who will be responsible for acting on the recommendations. In addition, the proposal speaks to potential costs of implementation. Proposal demonstrates the same level of achievement as “Meets,” plus the following: 2 to assess whether a patient safety plan is successful. © 2021 Walden University Proposal describes an evaluation method that is unrealistic and/or does not provide measurable criteria to evaluate success. Proposal describes an evaluation method that includes measurable criteria to evaluate success. Proposal describes an evaluation method that does not accurately determine if the patient safety plan is successful. Proposal describes an evaluation method that accurately determines if the patient safety plan is successful. Evaluation method provides a detailed description of data collection and quantitative analysis methods that will be used. 3 Overview In this Work Product Assessment, you will evaluate patient safety and quality data for a healthcare organization to identify an opportunity for error prevention. Based on this data, you will perform a Failure Mode and Effects Analysis (FMEA) to determine three probable causes for the errors. Then, you will develop a patient safety plan to help reduce the number of errors. This Assessment requires submission of one (1) document for all three parts of your Final Assessment. Save your file as OM004_firstinitial_lastname (for exle, OM004_J_Smith). You may submit a draft of your assignment to the Turnitin Draft Check area to check for authenticity. When you are ready to upload your completed Assessment, use the Assessment tab on the top navigation menu. Instructions Before submitting your Assessment, carefully review the rubric. This is the same rubric the assessor will use to evaluate your submission and it provides detailed criteria describing how to achieve or master the Competency. Many students find that understanding the requirements of the Assessment and the rubric criteria help them direct their focus and use their time most productively. Rubric Access the following to complete this Assessment: • Academic Writing Expectations Checklist The assessment has three-parts. Click each of the items below to complete this assessment. Part I: 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 Grade; Hospital Compare, maintained by the Centers for Medicare #038; 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 1- to 2-page analysis: o o Analyze three safety and quality results you found for the hospital such as: HCAHPS, pneumonia care, and emergency room treatment times. Describe the process and procedure used to access the data including a description of at least two websites that provide the data used. Part II: Failure Mode and Effects Analysis • Complete the FMEA (Failure Mode and Effects Analysis) Template, the fourth PDF under the “Download Documents” heading located at the bottom of the Institute of Healthcare Improvement website. To access the actual tool, you must complete an IHI registration (no cost). Use the tool 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 III: Patient Safety Plan Proposal • 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. Then, create a 3- to 5-page proposal in which you: o o Design a patient safety plan to address three areas of focus from the results of the FMEA. Describe an evaluation method to assess whether the patient safety plan is successful.
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