MMHA 6900 Walden University Analysis of a Quality Improvement Program Paper The Final Project is designed to give you an opportunity to analyze a quality i

MMHA 6900 Walden University Analysis of a Quality Improvement Program Paper The Final Project is designed to give you an opportunity to analyze a quality improvement program. You will analyze data related to benchmarks and national standards and suggest two goals for initiatives that address any deficiencies/opportunities in quality. Anticipated outcomes will also be identified, and appropriate time frames to re-evaluate data and provide a new analysis will be addressed.

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Read the case study Patient Safety at Grand River Hospital & St. Mary’s General Hospital in your Learning Resources.

Conduct an analysis of the case and write a 10- to 12-page (excluding title page and references) report including:

Data analysis against benchmarks and national standards
Observations about where quality improvements are needed
Goals for initiatives that address those deficiencies/opportunities in quality
Outcomes that are anticipated in order to accomplish the initiatives
Appropriate time frames to re-evaluate data and provide a new analysis. Justify your response
Note: Your Project must be written in standard edited English. Be sure to support your work with at least eight high-quality references, including four from peer-reviewed journals. Refer to the Essential Guide to APA Style for Walden Students to ensure that your in-text citations and reference list are correct. This Project will be graded using this rubric: Final Project Rubric (PDF). Your Project should show effective application of triangulation of content and resources in your conclusion and recommendations. S
Alex Cestnik and Ashok Sharma wrote this case under the supervision of Professor Murray Bryant solely to provide material for
class discussion. The authors do not intend to illustrate either effective or ineffective handling of a managerial situation. The authors
may have disguised certain names and other identifying information to protect confidentiality.
Richard Ivey School of Business Foundation prohibits any form of reproduction, storage or transmittal without its written permission.
Reproduction of this material is not covered under authorization by any reproduction rights organization. To order copies or request
permission to reproduce materials, contact Ivey Publishing, Richard Ivey School of Business Foundation, c/o Richard Ivey School of
Business, The University of Western Ontario, London, Ontario, Canada, N6A 3K7; phone (519) 661-3208; fax (519) 661-3882; email
Copyright © 2012, Richard Ivey School of Business Foundation
Version: 2012-11-21
After completing a comprehensive patient safety leadership fellowship in 2011, Dr. Ashok Sharma reflects
on how he could most positively impact his local medical community to develop a safety culture and
minimize medical errors. As the chief of staff at both Grand River Hospital and St. Mary’s General
Hospital in Kitchener-Waterloo, Ontario, Dr. Sharma would like to influence his practicing physicians
without threatening their professional autonomy or being perceived as paternalistic.
Despite being recognized as an area for improvement as early as the 1990s, the patient safety movement is
still in its infancy. Medical error remains a sensitive topic for patients, physicians, hospital administration
and virtually all who rely on health care, making the issue increasingly difficult to resolve. Only recently
has the topic been openly addressed, and there remains a significant gap between the care that is delivered
and that should be delivered.
A medical error is considered “the failure of a planned action to be completed as intended or the use of a
wrong plan to achieve an aim.”1 An adverse event refers to the additional harm that results from medical
mismanagement rather than the underlying disease. When an error results in an adverse event, it is
considered a preventable adverse event (see Exhibit 1). Research has suggested that approximately 10 per
cent of primary care medical errors result in patient harm.2 In 1997, large studies were completed in the
United States suggesting that as many as 98,000 Americans die each year due to medical error.3 This figure
positions medical error as the eighth leading cause of death, exceeding the number of deaths from motor
vehicle accidents and breast cancer combined. Such a mortality rate equates to one jumbo jet crashing each
Institute of Medicine (U.S.), To Err is Human: Building a Safer Health System, National Academy Press, Washington, DC,
This document is authorized for use only by Christopher Lopez in MMHA-6900-2,Healthcare Quality Management.2020 Spring Qtr 02/24-05/17-PT27 at Laureate Education – Walden
University, 2020.
Page 2
day. In response to the evident problem of inadequate patient safety, the National Patient Safety
Foundation (NPSF) was established in 1997. NPSF defines patient safety as “the avoidance, prevention
and amelioration of adverse outcomes or injuries stemming from the process of healthcare.”4 In 1999, the
Institute of Medicine (IOM) identified patient safety as an explicit concern when it proposed the six aims
of high-quality health care: safety, effectiveness, patient-centeredness, timeliness, efficiency and equity. In
order to improve safety, research has been conducted5 to better understand the underlying causes of
preventable adverse events. In general, two factors contribute to the likelihood of errors in any industry:
complexity and coupling. Complexity refers to the unpredictability of events, and coupling measures the
interdependence of tasks.6 Given that health care is both complex and tightly coupled, concerted efforts
must be made to prevent adverse events from occurring. There are a multitude of actions that can reduce
medical errors and improve patient safety, and they begin at an organizational rather than an individual
level. The IOM emphasizes that safety is a systemic property rather than an individual physician’s
“Unsafe acts are like mosquitoes: you can try to swat them one at a time, but there will always be others to
take their place. The only effective remedy is to drain the swamps in which they breed. In the case of errors
and violations, the “swamps” are equipment designs that promote operator error, bad communications,
high workloads, budgetary and commercial pressures, procedures that necessitate violations in order to get
the job done, inadequate organization and missing barriers and safeguards — the list is potentially long,
but all of these latent factors are, in theory, detectable and correctable before a mishap occurs.”7
Thus, patient safety is a systemic and cultural problem within the health care industry and cannot be
addressed by simply correcting or reprimanding the individual who errs. The solution requires analysis of
systemic failures related to factors such as equipment design and staff workload (see Exhibit 2). All
clinicians must be transparent about their errors and near misses in order to resolve underlying systemic
causes. Likewise, hospital administration must foster a safety culture in which physicians and other
clinicians can feel comfortable discussing errors and proactively seeking solutions.
Too frequently, physicians consider that patient safety is a product of a good clinical practice and not as
impacted by the broader system of patient care. A number of variables beyond an individual’s clinical
practice do play a role in patient safety including: technology, interdisciplinary care, physician trade-offs,
nursing staff, allied health professionals, medical device and product design, etc. Furthermore, the
organizational structure of hospitals suggests that responsibilities are diffused across many individuals. The
additional complexity resulting from the interaction of people and processes lead to a greater potential for
Following the movement towards improving patient safety, Health Canada established the Canadian
Patient Safety Institute (CPSI) in 2003 with an aim to “inspire extraordinary improvement in patient safety
and quality.”8 The institute develops evidence-based best practices, supports research, measures results,
Institute of Medicine (U.S.), To Err is Human: Building a Safer Health System, National Academy Press, Washington, DC,
James Reason and Alan Hobbs, Managing Maintenance Error: A Practical Guide, Ashgate Publishing Company,
Burlington, VT, 2003.
Institute of Medicine (U.S.), To Err is Human: Building a Safer Health System, National Academy Press, Washington, DC,
Canadian Patient Safety Institute, “About CPSI,”.,
accessed April 6, 2012.
This document is authorized for use only by Christopher Lopez in MMHA-6900-2,Healthcare Quality Management.2020 Spring Qtr 02/24-05/17-PT27 at Laureate Education – Walden
University, 2020.
Page 3
promotes communication, nurtures partnerships and celebrates successes. CPSI has implemented projects
and programs to work with all levels of the health care system, including frontline health care providers,
governments and educators. “Safer Healthcare Now!,” CPSI’s flagship program, provides clinicians with
the necessary tools and resources to improve health care quality through safety. CPSI relies on
collaborative efforts with governments, health care organizations and clinicians to accomplish the goal of
safer health care for all Canadians.
As awareness of inadequate patient safety increased, Canadian legislation began to change in order to
promote improvements in health care quality. On June 3, 2010, the government of Ontario passed Bill 46,
the Excellent Care for All Act, to “make health care providers and executives accountable for improving
patient care and enhance the patient experience.” In accordance with Bill 46, hospitals are required to
establish a quality committee to report directly to the board of directors. Hospitals must also develop and
publicize annual quality improvement plans (QIP). Additionally, hospitals are mandated to survey patients
yearly and employees every second year to collect their “views on the quality of care.” Lastly and
importantly, boards of directors are required to ensure that hospital executives are compensated according
to whether or not QIPs are met.9
In addition to Bill 46, on July 1, 2010, Regulation 156 of the Ontario Public Hospitals Act came into
effect; it requires that critical incidents be reported to the medical advisory committee (MAC) and hospital
administrators. A critical incident is “any unintended event that occurs when patients receive treatment in
hospitals that results in death, serious disability, injury, or harm, and does not result primarily from the
patient’s underlying condition or a known risk in providing treatment” (see Exhibits 3 and 4). Hospital
boards and administrators are legally required to ensure disclosure of critical incidents and establish
systems to analyze the reported incidents for root causes.10
In March 2012, the Ontario Ministry of Health and Long-Term Care announced that a patient-centred
funding model would be phased in over three years (see Exhibit 5). The intended benefits include a focus
on quality and evidence-based care, improved access and wait times, and an emphasis on cost containment.
The resulting funding composition for hospitals, community care access centres and long-term care homes
will ultimately be 70 per cent quality-based. The quality-based funding will be further divided to include a
40 per cent health-based allocation model (HBAM) and 30 per cent clinical quality groupings (see Exhibit
6). HBAM allocates a proportion of health care costs to each Ontario resident based on factors such as age,
sex, socioeconomic status, geography and clinical group. Each resident’s allocated cost is associated with
the organization that provides their care, and these health care providers are given funding based on this
predicted cost. Clinical quality grouping funding is calculated by multiplying the determined price to
provide quality treatment for a particular condition (such as chronic kidney disease, cataract surgery, hip
replacement, etc.) by the expected volume for the health care organization. The remaining 30 per cent will
be global funding, reduced from 54 per cent in April 2012. Overall, the government of Ontario’s funding
reform is intended to increase quality, appropriateness and sustainability of care for patients and the overall
health care system. 11
Ashok Sharma, et al., Physician Matters [Kitchener-Waterloo], 2010, Web. January 18, 2012.
“How Does HBAM work?: Step-By-Step Demonstration,” 2012, pages 3-6. Web. April 12, 2012.
This document is authorized for use only by Christopher Lopez in MMHA-6900-2,Healthcare Quality Management.2020 Spring Qtr 02/24-05/17-PT27 at Laureate Education – Walden
University, 2020.
Page 4
Even prior to Bill 46, disclosure of critical incidents to patients was mandated by law, and most hospitals
had systems to collect reports on such events. Yet, there remain several problems with critical incident
reporting in health care organizations. First, underreporting is a challenge because physicians often fear
professional criticism or legal repercussions. The Quality of Care Information Protection Act (QCIPA) of
2004 provides statutory protection of information collected for the purposes of quality assessment and
improvement. Thus, under QCIPA, clinicians are protected from legal action resulting from information
disclosed to improve quality. Following each critical incident report, QCIPA reviews are held by hospital
administration with all individuals involved in the critical incident. The result of QCIPA reviews are
summaries of improvements to be made. However, in addition to underreporting, clinicians often do not
attend the QCIPA reviews, even if attendance is mandatory, because they fear legal consequences and
recognize that attendance is not enforceable. Thus, although a healthcare organization’s chief of staff may
have authoritative power, individual physicians are largely independent entrepreneurs.
A second challenge with critical incident reporting is that the information collected from reports is often
inadequate and variable. Reporters tend to cite individual rather than systemic factors as the root cause of
adverse events. Given that reporters were most often physicians or clinicians, they are close to the error at
the “proximal side” or “sharp end” of the problem. As a result, they do not consider latent errors that
occurred in the overall system at the “distal end” of the problem. Attempts were made to improve this
through educating medical students and practicing clinicians to develop a “systems” view of medical
In addition to education, effective reporting requires a non-punitive environment so that clinicians are
comfortable reporting incidents, including detailed accounts and sharing near misses. Reporting
questionnaires are most effective when they are open-ended, allowing the reporter to develop a story of the
event. This format results in reports that provide a broader systemic picture and often include more detail
than if the survey were more specific. Overall, reporting can be a useful tool to improve patient safety and
prevent recurrences of critical incidents, yet it remains a reactive strategy. Greater efforts and initiatives by
all individuals are required to foster a safety culture that promotes proactive problem-solving.
In order for the benefits of CPSI, regulatory advances and incident reporting to be realized, health care
organizations must develop a safety culture. A safety culture refers to an environment in which the desire
to achieve greater safety is apparent in intangible beliefs, attitudes and values in addition to concrete
structures, practices and policies. In a safety culture, clinicians and administrators do not expect that each
individual will be flawless; rather, they understand that people are imperfect and that failures are
inevitable. As a result, there is a heightened diligence to detect errors and to implement defences that will
prevent adverse outcomes. These attitudes and behaviours exist throughout the organization from the
administration to the frontline clinicians and will persist through changes ton senior management. Once a
safety culture is achieved, reporting becomes more frequent and complete, and near misses are willingly
shared for greater quality improvement. In order to achieve such a result, a significant amount of trust must
exist among care providers so that adverse events may be openly discussed and solutions developed
through collaboration. A safety culture is not a static state but a dynamic system that is constantly changing
as opportunities arise.
This document is authorized for use only by Christopher Lopez in MMHA-6900-2,Healthcare Quality Management.2020 Spring Qtr 02/24-05/17-PT27 at Laureate Education – Walden
University, 2020.
Page 5
Grand River Hospital (GRH) is one of Ontario’s largest community hospitals with over 3,500 staff
members working towards their stated vision of being a “leader in providing 24/7 patient care programs
through innovation and collaboration, within available resources.” In 2010/11, 23,391 patients were
admitted with 12,671 day surgery visits, 58,596 emergency visits and 210,557 ambulatory care visits. GRH
developed a quality framework, which includes a quality and patient safety committee, a senior quality
team and clinical programs and services quality councils to hold the hospital accountable for quality and
safety (see Exhibit 7). The hospital continually evaluates itself on four dimensions: access to care,
appropriateness of care, safety of care and patient experience with care. GRH uses benchmark indicators to
assess its performance and track its progress. This analysis is made available to the public to demonstrate
transparency and openness.
St. Mary’s General Hospital (SMGH) has been providing health care in the Kitchener community since
1924. The hospital has nearly 2,000 staff and volunteers that annually support more than 7,000 admissions,
100,000 outpatient visits, 47,000 emergency visits and 20,000 surgical procedures. SMGH instituted their
new vision in 2011/12 of becoming the “safest and most effective hospital in Canada characterized by
innovation, compassion and respect.” University of Waterloo management science researchers have
partnered with SMGH to conduct deep analyses of actions and outcomes within the hospital. SMGH
frequently employes “lean” management techniques to achieve continuous improvement on the frontlines
of health care delivery. To encourage bedside initiatives, SMGH announced a goal to implement 1,000
measurable improvements in one year and reported on multiple successes to recognize and celebrate
employees’ efforts. SMGH also has a guiding quality committee framework and an algorithm of actions
following critical incidents (see Exhibits 8 and 9).
Given their proximity to one another, GRH and SMGH partner to specialize in certain procedures. They
are both committed to being leaders in patient safety and quality of care, and as such, have begun various
efforts to accomplish their visions. Nonetheless, Dr. Sharma believes that significant improvements can
still be made to patient safety in both hospitals. The hospitals had yet to adopt a true safety culture from
administrative to frontline levels, and this is hindering improvement to quality of care. As evidenced by
underreporting and poor attendance at QCIPA reviews, there is a lack of physician buy-in to many quality
improvement efforts. Dr. Sharma’s greatest challenge is influencing the intangible aspects that define a
safety culture – the attitudes, beliefs and values of clinicians. Over a decade of pressure from the IOM,
increased legislative requirements, QCIPA legal protection, administrative encouragement and
demonstrated positive outcomes have all been insufficient to truly change physicians’ attitudes and
Dr. Sharma has considered making adjustments to the hospitals’ organizational structures to formalize
leadership positions and increase accountability on quality metrics. He looked to the example of
Mississauga’s Trillium Health Centre, which included patient safety accountability in the job descriptions
of department chiefs to assign responsibility for quality of care. They also developed quality competitions
to recognize staff contributions to patient safety improvements. These initiatives were launched following
a decade’s worth of monthly workshops to collaborate and train staff. The successes resulting from
Trillium’s efforts are not guaranteed to be replicated in other health care organizations, but they are
certainly attributable to physician leadership and grassroots participation.12
Dr. Sharma is also aware of the importance of teamwork and communication (T&C) skills to provide the
highest levels of patient satisfaction. The IOM recognized the lack of training in T&C and called for
Ashok Sharma, et al., Physician Matters [Kitchener-Waterloo…
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