Nursing Project Executive Summary Assignment

NRS 451v GC Week 3 Executive Summary Benchmark Assessment

Nursing Project Executive Summary Assignment

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Patient safety is one of the critical areas in a healthcare setting. It is crucial for healthcare organizations to develop a range of practices that enhance patient safety. Healthcare organization administrators must thus determine various risks that can reduce patient’s safety. Besides, various government authorities stipulate specific rules and guidelines that foster high-quality patient care and safety. This paper provides a summary of multiple tools and practices that permit quality improvement in healthcare organizations while managing risks and demonstrating compliance to the set regulations. In this regard, this document explains the various rules relating to data breaches and patient information-security risk management procedures and compliance practices. Although the realization of useful quality improvement is engaging, quality improvement is highly inevitable towards meeting today’s healthcare demands. To realize this, an organization can use a range of quality improvement tools.

One of the most effective tools for quality improvement is the “cause and effect diagram.” For a healthcare organization to be successful, it must demonstrate a high level of information organization. Cause and effect diagrams help the nurses, physicians, and other healthcare workers to determine the cause and effects of certain occurrences in an organization. This tool allows the administrators and other employees to examine why something happens or might occur by clearly organizing all possible causes into lesser categories. The tool is also helpful in showing associations between the contributing factors. Another useful tool for quality improvement is the flow diagrams. Like many other organizations with critical procedures and processes, healthcare organizations should use flow diagrams to enhance operations and systems. Besides, forms are practical quality improvement tools as they help to collect credible information from different sources. Other useful tools include the run charts for determining the variations in unique and common causes of an event and Gantt charts for successful project management.

While using the above tools, a healthcare organization can achieve the best quality improvement practices. Some of these practices include “adaptive leadership, culture and governance,” effective analytics, consensus, and evidence-based practices as well as financial alignment. Usually, Healthcare administrators must understand the best practices to ensure that they develop effective quality improvement programs. Active quality improvement initiatives demand enhanced senior leadership support in addition to an adaptive learning culture, emphasizing on quality improvement based on credible data. As such, adaptive leadership and culture serve the best interest of the organization, employees, and the patient.

Analytics culture is one of the most effective practices toward sustainable quality improvement. Notably, analytics play critical roles in all phases in the quality improvement lifecycle- including planning, doing, studying, and acting. Analytics enhance processes involved in measuring and understanding various challenges as well as to determine whether the outcomes promote quality improvement. Notably, it is not obvious that an organization has quality improvement because it has measurements. Of importance, evidence-based practices permit quality improvement and patient safety, among other healthcare benefits (Schwappach, Frank,  Buschmann & Babst, 2013). However, quality improvement efforts are meaningless without adoption. As such, making adequate plans and implementing the best practices is essential for healthcare organizations.

Also, an organization that implements the best practices must not only recognize but also comply with the set rules and regulations.  Some of the most fundamental rules that every health provider must comply with are the HIPAA rules (Harman, Flite & Bond, 2012). For instance, the government HIPAA Security Rule requires the “organizations to conduct numerous audit trails” to understand the users using specific information, data, or processes in the system at a particular time (American College of Healthcare Executives, 2007). Besides, organizations must also ensure that they have the right software and hardware while adhering to the “correct procedures recording and examining activities in systems containing protected health information.” Hospitals and other healthcare facilities should comply with the HITECH Act (2009) requirements (Morello et al., 2013). For instance, the law requires hospitals and other healthcare facilities to watch for personal health data breaches from either external or internal intrusions. As such, facilities must protect the patients and the workers at all times in addition to providing high-quality health services. Compliance with these regulations allows organizations to limit any data breaches (Okuyama, Wagner & Bijnen, 2014).

While implementing the best practices, healthcare organization realizes the potential risks to the entire organization, including the patient, employees, data, and information as well as processes and procedures. Risk management is thus, very crucial for quality improvement. In the contemporary world, various organizations are emphasizing risk management to allow continuity in case any risk occurs but, more importantly, to ensure that risks do not happen. Risk management practices help to mitigate against risks or reduce the impacts of the risks and permit continuity.

In light of this, healthcare administrators must understand various risk management techniques, including avoidance and retention, as well as reduction and sharing strategies. Understanding the risk management process is also essential for the administrators and risk managers. Notably, risk management processes involve a range of phases including identification of the risk, assessment of the possible impacts from the risk, and the control of the risk as well as a useful review of the process to ensure efficiency.



American College of Healthcare Executives. (2007). ACHE code of ethics.

Harman, L. B., Flite, C. A., & Bond, K. (2012). Electronic health records: privacy, confidentiality, and security. AMA Journal of Ethics, 14(9), 712-719. Retrieved from

Morello, R. T., Lowthian, J. A., Barker, A. L., McGinnes, R., Dunt, D., & Brand, C. (2013). Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Qual Saf, 22(1), 11-18.

Okuyama, A., Wagner, C., & Bijnen, B. (2014). Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC health services research, 14(1), 61.

Schwappach, D. L., Frank, O., Buschmann, U., & Babst, R. (2013). Effects of an educational patient safety campaign on patients’ safety behaviors and adverse events. Journal of Evaluation in Clinical Practice, 19(2), 285-291.

There is quite a range of topics on improving patient safety that I have thought about writing. However, I have decided on addressing handwashing among patients admitted in care facilities. The reasons why I chose this heading is due to the frequent adverse events related to healthcare-associated infections (HAIs) among hospitalized patients. I have also realized that there are several infection prevention and control (IPC) strategies in hospitals but most of such practices give preference to healthcare providers as opposed to patients who are the recipient of medical intervention (Pittet et al., 2017). Attention has been on the effectiveness of handwashing practices that guarantee safety to patients. Even though hand hygiene has been widely promoted across the world, specific concerns still remain on the best practices that ensure optimal protection to patients. The challenges of proper hand washing in healthcare system among patients are unexpected but continue to suffice. In my visit to one of the public hospitals in Los Angeles, I realized that effective handwashing techniques are not followed by the patients to the latter. This is due to the unreliable supply of liquid soap and alcohol handrubs to achieve the three stages of handwashing. Besides, even when these agents are available, some patients lacked knowledge on proper techniques of handwashing as some start with alcohol handrub and ends by using the soap. This calls for an initiative by care facilities to inform patients about the handwashing protocols. The education on handwashing can be addressed during bedside services or patients sensitized during health education forums organized by the care facility.



Pittet, D., Boyce, J. M., & Allegranzi, B. (Eds.). (2017). Hand hygiene: a handbook for medical professionals (Vol. 9). John Wiley & Sons.