QI and Patient Safety Infrastructure Assessment

The purpose of this assignment is to provide students with the opportunity to assess and become familiar with the quality and safety infrastructure within their respective healthcare

organizations. Use the dedicated discussion forum in Blackboard for this assignment. Review these instructions and the evaluation criteria outlined in the grading rubric carefully before you

begin to avoid unnecessary loss of points on this assignment. This assignment constitutes 5% of your grade for this course.

1. Review the quality and patient safety infrastructure checklist on page 2.
2. Conduct an assessment of the quality and safety infrastructure of your organization using the checklist as a guide. Note that an in-depth assessment is beyond the scope of this discussion

board assignment and you may not be able to gather information in every category. You may want to start by scheduling time to talk with any designated QI/Safety coordinators in your

agency, or the manager of your work area.
3. In an initial discussion board posting, describe (a) the type of setting where you work and (b) the results of your assessment by responding to at least four of the following questions or

statements. You do not need to identify your organization by name—just setting type (e.g., hospital, emergency room, primary care, long term care, etc.).
o Which infrastructure components exist within your organization? Which don’t?
o Is the organization accredited or certified by one or more quality-focused credentialing bodies (e.g., Joint Commission, ANCC/Magnet, NCQA). How does this impact the organization’s

approach to quality and safety?
o Has the organization adopted one or more standardized approaches to QI (e.g., Lean, Six Sigma, PDSA)? How is it implemented?
o Which individual(s), committee(s), and/or team(s) are primarily responsible for quality and safety within your organization? Briefly describe their roles and responsibilities. Note: Do not provide

identifying information (names) for specific individuals—use positions/titles only.
o Does the organization have global or strategic QI/patient safety priorities? What are they? How are they currently being implemented?
o Is information technology used to support quality and safety activities? How?
o Describe the reporting systems in place to support quality and safety (e.g., quality reports, incident reporting systems, sentinel event reporting procedures, etc.).
o How is quality and/or safety currently measured at the organizational level or within your unit? Provide one or more examples of key measures.
o Describe the types of quality and safety training available for staff.
o Describe any rewards or recognition programs to specifically promote quality and safety behaviors.

This is a discussion board. In depth analysis is not required—focus on key points and strive for clarity and conciseness. Be sure to get your initial and reply posts on the discussion board in a

timely manner to provide time for responses and further discussion (i.e., no later than day four of the discussion period). Include any relevant reference citations in APA format.

Quality and Safety Infrastructure Checklist Relevant/Possible Questions to Consider
Healthcare professionals responsible for quality and safety What is their job title? Is this their primary responsibility in the organization? What are their roles/responsibilities relative to quality

and safety?
Quality and safety teams/committees What is the name of the group? What are their roles/responsibilities relative to quality and safety? Who do they report to?
Accreditation and/or certification Is the organization accredited or certified by one or more QI/safety credentialing organizations (e.g., Leapfrog, Joint Commission, NCQA, ANCC/Magnet)?

Which one? How does this relate to quality and safety practices within the organization?
Planning documents, policies and procedures to support quality and safety improvements What types of documents exist to support quality and safety improvement in the organization? Is

there a global QI and/or patient safety plan? Where are the documents located (physical location, online, etc.)?
Standardized approach to quality/safety Has the organization adopted a standardized approach to QI (e.g., Lean, Six Sigma, etc.)? Which one? How is it implemented?
Established quality and safety priorities Have these been established and communicated to staff? How? What projects or initiatives are in place to support achievement of these priorities?
Data collection and reporting systems What information technology systems are in place to support data collection and reporting? How is it used? Who is responsible for reporting? What

systems or processes are in place for incident and/or serious event reporting?
Quality measurement system(s) How are quality and safety measured? What specific indicator measures are being used? Are standardized measures (e.g., HEDIS, CAHPS) used? Which ones?
Quality and safety training What QI or safety training programs for staff are available? Who is responsible for providing the training? When and where does it occur?
Rewards and/or recognition programs What rewards or recognition programs or mechanisms are in place to promote and reinforce quality- and safety-related behaviors?

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