BHA FPX 4004 Assessment 3 Collaborate on Quality Issue Analysis and Leadership Plan

BHA FPX 4004 Assessment 3 Collaborate on Quality Issue Analysis and Leadership Plan:

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Leadership Plan and Issue Analysis

In order to maximize the performance of the healthcare system, I will apply the Triple Aim organization leadership strategy from the Institute for Healthcare Improvement (IHI) throughout this essay and offer examples. Second, offer collaborations, leadership techniques, and evidence-based action plans that can help create a culture of safety and quality. Finally, work out how to include the organization’s leaders and governing board in promoting a just and equitable hospital culture.

Overview of the Problem

Kyra Dilla, the patient safety officer at Vila Health, saw two patients sharing the same name and occupying the same room on the same level during her unit rounds. Given how similar the names are, there is a significant chance that a patient misidentification error may occur. Furthermore, the birthdays of the two patients are nearly identical. When Patient Safety Officer Dilla brought up her concerns with the lead nurse on the unit, she was told that each patient has a separate nurse and that appropriate documentation is made in each chart to prevent patient misidentification.

My intention in bringing up this matter is to inform hospital staff members of the potential repercussions should a patient with the same name be mistakenly identified. Secondly, devise tactics that can help reduce the possibility of misidentification errors. Most importantly, stop Vila Health system from facing costly lawsuits for using inappropriate treatment techniques on individuals who weren’t properly recognized. 

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IHI Triple Objective

Established in 1991, the Institute for Healthcare Improvement (IHI) is a self-governing, nonprofit organization with a primary goal of advancing and enhancing the quality of healthcare for both patients and healthcare providers (Tenkorang-Twum et al., 2024). The Triple AIM program was created by the IHI thorough investigation. The goal of this effort was to improve population health, lower the per capita cost of healthcare, and enhance patient experiences .

There are several reasons why a company should pursue the Triple Aim. For instance, Wisconsin-based QuadMed, a printing shop, developed an on-site employer-based healthcare plan. Under this initiative, 22,000 workers and their families had complete access to lab, x-ray, and primary care services. By providing these on-site services, QuadMed was able to save a third of the cost of health care services per employee when compared to other Wisconsin-based businesses (Al Jasser & Almoajel, 2020).

The Vila health care mission is reaffirmed by the IHI Triple Aim initiative, which is applicable to this occurrence. The goal of the hospital is to give patients the best possible care that is safe. In the process of providing accessible and reasonably priced healthcare, community health will improve. The Triple Aim component that I will apply to the success of my business is the enhancement of patient quality and satisfaction with the quality of patient treatment, with a primary focus on patient safety.

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The Traditions

According to Kokko ( 2022), culture refers to the environment, attitudes, actions, beliefs, and expectations of a health institution in relation to its mission to provide healthcare. An organization’s culture in the health sector is crucial. After closely analyzing a patient safety concern, I’ve come to the conclusion that Vila Health system culture as it currently exists clearly understands patient safety and prevention. PSO Dilla’s observation of the patients with the same names helped me come to this conclusion. Notifying the charge nurse and asking about the measures taken to avoid the patients’ identities being mixed up are also important.

Three elements will make up the strategies I use to foster a culture of safety inside the healthcare system. First, restate the mission, vision, values, and objectives of Vila Health (Kokko, 2022). Clearly and succinctly stating each idea via meetings, associate seminars, trainings, and video displays across the hospital system. In an effort to be transparent, going ahead, all employees of the hospital system will experience the new culture. Second, encourage a culture of faith in the hospital’s administration.

According to Bachynsky ( 2019), management that fosters a culture of employee safety will increase employee engagement. A culture of loyalty and dedication will emerge in the workplace as a result of employee faith in management.Finally, make the proper hire. Hire people who are very talented and who will support the updated culture of the system. Red flags that show a candidate’s vision is at odds with the hospital’s future endeavors are frequently ignored by the leadership (Bachynsky, 2019).

Cooperation

Errors in identification are complex and have an impact on the health system as a whole. The hospital’s risk management division and each department that deals with nursing will be the main contributors to attempts to reduce errors through corrective action. My selection of these departments was based on the development of hospital policies, their execution, and training of the clinical staff who have the closest patient encounters.

A hospital’s risk management division actively strives to avert situations that can lead to losses or legal responsibility. Losses or liabilities in a hospital context may include prescription drug errors, surgical errors, diagnostic errors, privacy violations, and hazardous situations (Kadakia, 2024) . Despite the fact that the Vila’s Health system has different nursing departments based on specializations, each discipline’s essential principles are the same. And the cornerstone of every specialty is patient safety.

The execution of these modifications is the responsibility of all Vila Health associates, whether clinical and non-clinical. Nevertheless, the hospital’s Chief Compliance Officer (CCO), a Clinical Nurse Specialist, and a nurse assigned to the floor in question are the three specific colleagues who I will involve and hold accountable for the execution of my action plan. The CCO’s job will be to guide and advise on how to make the recommended action plan better. Additionally, recommend actions the hospital might take to comply with Joint Commission compliance rules on patient identification guidelines. Second, assign the clinical nurse specialist the responsibility of developing evidence-based strategies to enhance hospital system identification approaches for patients (Kadakia, 2024). 

Lastly, the task two nurses assigned to the concerned floor are to discuss and reinforce patient misidentification prevention strategies with their unit counterparts.The consequences of not working with all departments to promote safety and quality will weaken the culture of the health system and impede professional growth. Negative departmental failure patterns and recurrent sentinel events will result from the failure to implement quality improvement and clinical safety correctives.

I would create an obligatory health system training that would take place over the course of a week in order to involve all departments in correcting this patient identification problem and strengthening the hospital’s culture (Niv & Tal, 2023). Team-building activities, forums for leaders across departments, roundtable talks with senior leadership, and other activities are planned for the workshop, all of which center on the hospital’s efforts to reduce and avoid mistakes in patient identification and to change the hospital’s culture.

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Management

The patient safety officer at each hospital is a designated leader who could help solve this issue and prioritize patient safety and quality throughout the company. Patient safety officers (PSOs) in hospitals locate, gather, and evaluate issues that could compromise patient safety within the institution’s healthcare system. PSOs take on the function of serving as a point of contact for patients, frontline employees, and higher management. Actions are being taken to address and resolve these concerns as policies are being developed.

I will provide a four-point proposal in an attempt to get the hospital’s Patient Safety Officer involved in efforts to lower patient identification errors. Weekly rounds, an event reporting system, safety measures, and hospital staff retraining are all part of the plan. yearly reeducation of medical staff through the assignment of mandatory hospital competences on TJC identification laws and hospital standards. Second, conduct weekly rounds with unit managers and doctors present.

During these rounds, emphasize to staff the importance of accurately and consistently checking patient wrist bands and using two identities when identifying patients. Thirdly, put preventive measures in place, such as a two-person check system (Al-Sa’d et al., 2022).A second healthcare provider will make that the right patient is receiving medication or blood work before any of it is given. 

Finally, put in place an incident recording system that allows employees to self-report on occurrences and suggest the best course of action for averting future mishaps.

For this campaign to be successful, the organization’s governing body needs to be in the forefront. Every board member should participate in the weekly hospital rounding and re-education session, in my opinion. If the board shows opposition, I will reaffirm that leadership involvement and transparency are necessary for culture transformation. Additionally, being visible demonstrates leadership and lets all colleagues within the healthcare system know that higher-level executives are driving improvements in patient safety and quality of treatment (Ostrander et al., 2020).Consequently, setting an example of the change is the most effective way to convey to colleagues the need for change.

Plan of Action for Leadership

Implementing safety procedures for patients with similar names, involving patients in the identification process throughout their care, and emphasizing to all hospital staff the significance of accurate patient identification are the three evidence-based actions that I would suggest to address this incident. One proactive step that needs to be taken to avoid errors is to establish appropriate procedures for patients with similar names. According to Nicola et al 

(2020), in the event of patient misidentification, safety procedures should be explained to all staff members on the unit. To prevent inconsistencies, alternative identifiers must also be utilized. Patient B. Moore’s identify, for instance, would be her name and date of birth, but Patient B.R. Moore’s would be her medical record number and her last six social security digits. 

Second, let patients participate in the process of identification. Nicola et al., (2020) adds that it is best to refrain from asking leading questions while confirming a patient’s identity because patients are frequently confused and stressed during their hospital stay. Ask open-ended inquiries instead, like “please tell me your name.” To ensure accuracy and further confirmation, have patients read their name and birthdate on their wristband. 

Finally, training personnel on the significance of patient identity. Despite the fact that medical staff members are aware of the significance of patient identity, misidentification is nevertheless increasing.All staff members will get yearly training on patient safety procedures, which will highlight the hospital’s compliance with The Joint Commission’s standards. Staff members who disregard these directives will be in breach of them. Employees who frequently make mistakes in patient identification should also get the appropriate training and instruction on the significance of following hospital identification protocols (Morris et al., 2019).

Installing patient registration kiosks, using multiple factor authentication, and using patient photographs as an additional identity are the three evidence-based approaches that I would suggest to address this issue. These days, patient safety is a major concern, and best attempts just won’t cut it. According to Hofmeyer & Taylor (2020), taking a patient’s picture and adding it to their medical file can prevent medical identity fraud and help medical staff in the future when confirming the identity of the patient they are treating. Furthermore, combining the authentication methods used by security and financial firms can help avoid mistakes in patient identification in hospitals. The norm for patient verification in health systems need to be the utilization of various factors of authentication. 

Names and birthdates are useful identification variables, but it’s better to include three or four, such as the patient’s home address, driver’s license number, and other identifiers. According to Butler (2020), hospitals are coming up with creative techniques to make sure staff members are recognizing the correct patient and that every patient that walks through the door is who they say they are. When a patient’s demographics are recorded into the hospital’s database erroneously, the process of incorrect patient identification commences. While entering patient data, frontline staff members could make a clerical error. Installing patient registration kiosks may help to lessen this. 

Among these advantages is the freedom for patients to enter and confirm their own personal information. Furthermore, Kios systems have the ability to remove duplicate patient charts and identify patients with identical names and dates of birth (Hofmeyer & Taylor, 2020). While these procedures and methods are not foolproof, they can help lower the frequency of patient identification errors if they are implemented and carried out correctly.

BHA FPX 4004 Assessment 3 Collaborate on Quality Issue Analysis and Leadership Plan

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Conclusion

The cornerstone of initiatives to raise patient safety and quality is a safety culture. The success of this endeavor is largely due to the unity and leadership of upper management. Reducing patient identification errors can be facilitated by establishing a transparent culture with training and policies centered on patient safety and well-being. A hospital that is unaware of a large financial risk is impacted by patient misidentification. Vila Health can enhance patient and visitor safety by means of numerous means, including research, data collection, staff education, and adherence to regulatory procedures.

References

Al Jasser, B., & Almoajel, A. (2020). Adopting the Triple Aim Framework in the Saudi Healthcare System: A Delphi Study. Risk Management and Healthcare Policy, Volume 13, 2189–2197. https://doi.org/10.2147/rmhp.s251008

Al-Sa’d, M., Kiranyaz, S., Ahmad, I., Sundell, C., Vakkuri, M., & Gabbouj, M. (2022). A Social Distance Estimation and Crowd Monitoring System for Surveillance Cameras. Sensors, 22(2), 418. https://doi.org/10.3390/s22020418

Bachynsky, N. (2019). Implications for policy: The Triple Aim, Quadruple Aim, and interprofessional collaboration. Nursing Forum, 55(1), 54–64. https://doi.org/10.1111/nuf.12382

Hofmeyer, A., & Taylor, R. (2020). Strategies and resources for nurse leaders to use to lead with empathy and prudence so they understand and address sources of anxiety among nurses practising in the era of COVID‐19. Journal of Clinical Nursing, 30(1-2), 298–305. https://doi.org/10.1111/jocn.15520

Kadakia, E. (2024). NAVIGATING THE COMPLEXITIES OF MEDICAL ERROR AND ITS ETHICAL IMPLICATIONS. Scholarshare.temple.edu. https://scholarshare.temple.edu/handle/20.500.12613/10329

Kokko, P. (2022). Improving the value of healthcare systems using the Triple Aim framework: A systematic literature review. Health Policy, 126(4), 302–309. https://doi.org/10.1016/j.healthpol.2022.02.005

Morris, J. E., Lummis, G. W., Lock, G., Ferguson, C., Hill, S., & Nykiel, A. (2019). The role of leadership in establishing a positive staff culture in a secondary school. Educational Management Administration & Leadership, 48(5), 174114321986493. https://doi.org/10.1177/1741143219864937

Nicola, M., Sohrabi, C., Mathew, G., Kerwan, A., Al-Jabir, A., Griffin, M., Agha, M., & Agha, R. (2020). Health Policy and Leadership Models During the COVID-19 Pandemic- Review Article. International Journal of Surgery, 81, 122–129. https://doi.org/10.1016/j.ijsu.2020.07.026

Niv, Y., & Tal, Y. (2023). Medico-Legal Aspects of Patient Safety and Risk Management. 95–109. https://doi.org/10.1007/978-3-031-49865-7_8

Ostrander, A., Bonner, D., Walton, J., Slavina, A., Ouverson, K., Kohl, A., Gilbert, S., Dorneich, M., Sinatra, A., & Winer, E. (2020). Evaluation of an intelligent team tutoring system for a collaborative two-person problem: Surveillance. Computers in Human Behavior, 104, 105873. https://doi.org/10.1016/j.chb.2019.01.006

Tenkorang-Twum, D., Atibila, F., & Gyapong, P. (2024). Analysis of the Ghanaian Health System and Patients Safety within the IHI Triple Aim Framework. Ghana Journal of Nursing and Midwifery, 1(2), 1–9. https://doi.org/10.69600/.v01.i02.01-09

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