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Write a 3–5 page safety score improvement plan for mitigating concerns, addressing a specific patient-safety goal that is relevant to quality patient care. Determine what a best evidence-based practice is and design a plan for resolving issues resulting from not maintaining patient safety.

Quality improvement and patient safety are health care industry imperatives (Institute of Medicine’s Committee on Quality of Health Care in America, 2001). Effective quality improvement results in system and organizational change. This ultimately contributes to the creation of a patient safety culture.


By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

  • Competency 2: Apply systems theory and systems thinking to facilitate health care delivery and patient outcomes.
    • Apply systems thinking to explain how current policies and procedures may affect an identified safety issue.
    • Explain an evidence-based strategy to collect information about, and improve, an identified safety concern.
    • Explain a plan to implement a recommendation and monitor outcomes.
  • Competency 4: Evaluate how power relates to health care organizational structure, behavior, and leadership.
    • Describe the influence of nursing leadership in driving needed changes.
  • Competency 5: Communicate in a manner that is consistent with the expectations of a nursing professional.
    • Write content clearly and logically, with correct use of grammar, punctuation, mechanics, and current APA style.




Quality improvement and patient safety are health care industry imperatives (Institute of Medicine’s Committee on Quality of Health Care in America, 2001). Effective quality improvement results in system and organizational change. This ultimately contributes to the creation of a patient safety culture.


Quality improvement and patient safety are central to the nursing leadership role. They are analyzed from many perspectives. Types of quality improvement and patient safety programs may range from internal, organization-based quality improvement team reports to external benchmarks from The Joint Commission, the Agency for Healthcare Research and Quality (AHRQ), Magnet, and numerous other organizations.

A landmark publication by the Institute of Medicine’s Committee on Quality of Health Care in America (2001) identified the imperative to focus on quality care and patient safety. The initiative to create cultures of patient safety and quality care remain at the forefront of the health care leadership landscape. Nursing leadership sub-competencies include the understanding of components and use of effective tools for successful quality improvement programs within the practice setting.

For a more recent snapshot of progress in the arena of patient safety, you may review a recent executive summary database report on safety cultures from the U.S. Department of Health & Human Services (n.d.). Lessons learned and tools presented within the directed readings provide a rich set of resources from which to draw for improved nurse leadership in the area of patient safety.




To deepen your understanding, you are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of the health care community.

Consider a performance measurement criteria or best practice guideline used in your work setting (or one that you are familiar with).

  • How was this criterion or guideline implemented?
    • Has it been successful?
    • Is it used consistently?
  • What evidence-based practices were used in developing the criteria or guideline?
  • How was nursing involved in the criteria or guideline development?




Suggested Resources

The following optional resources are provided to support you in completing the assessment or to provide a helpful context. For additional resources, refer to the Research Resources and Supplemental Resources in the left navigation menu of your courseroom.

Capella Media

Click the link provided below to view the following multimedia piece:

  • Systems Theory and the Fifth Discipline| Transcript.


Library Resources

The following e-books or articles from the Capella University Library are linked directly in this course:

  • Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education for nurses (QSEN): The key is systems thinking. Online Journal of Issues in Nursing, 18(3), 71–80.
  • Kim, D. H., & Senge, P. M. (1994). Putting systems thinking into practice. System Dynamics Review, 10(2/3), 277–290.
  • Sullivan, D. T. (2010). Connecting nursing education and practice: A focus on shared goals for quality and safety. Creative Nursing, 16(1), 37–43.
  • Burke, K. M., & Hellwig, S. D. (2011). Education in high performing hospitals: Using the Baldrige framework to demonstrate positive outcomes. The Journal of Continuing Education in Nursing, 42(7), 299–305.
  • Squires, M., Tourangeau, A., Laschinger, H. K. S., & Doran, D. (2010). The link between leadership and safety outcomes in hospitals. Journal of Nursing Management, 18(8), 914–925.
  • Morath, J. (2011). Nurses create a culture of patient safety: It takes more than projects. Online Journal of Issues in Nursing, 16(3), 2.
  • Gagnon, M-P., Desmartis, M., Labrecque, M., Car, J., Pagliari, C., Pluye, P., . . . Légaré, F. (2012). Systematic review of factors influencing the adoption of information and communication technologies by healthcare professionals. Journal of Medical Systems, 36(1), 241–277.
  • Melnyk, B. M., Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan, L. (2012). The state of evidence-based practice in US nurses: Critical implications for nurse leaders and educators. The Journal of Nursing Administration, 42(9), 410–417.
  • Stimpfel, A. W., & Aiken, L. H. (2013). Hospital staff nurses’ shift length associated with safety and quality of care. Journal of Nursing Care Quality, 28(2), 122–129.

Course Library Guide

A Capella University library guide has been created specifically for your use in this course. You are encouraged to refer to the resources in the BSN-FP4008 – Organizational and Systems Management for Quality Outcomes Library Guide to help direct your research.

Internet Resources

Access the following resources by clicking the links provided. Please note that URLs change frequently. Permissions for the following links have been either granted or deemed appropriate for educational use at the time of course publication.

  • Hospital Safety Score. (n.d.). What is patient safety?Retrieved from http://www.hospitalsafetyscore.org/what-is-patient-safety
  • Agency for Healthcare Research and Quality. (n.d.). AHRQ. Retrieved from http://www.ahrq.gov
  • National Academy of Medicine. (n.d.). Retrieved from http://nam.edu
  • Centers for Medicare & Medicaid Services. (n.d.). Hospital-acquired conditions. Retrieved from https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitalacqcond/hospital-acquired_conditions.html
  • American Nursing Informatics Association. (n.d.). ANIA. Retrieved from https://www.ania.org/
  • (n.d.). Nursing informatics. Retrieved from http://www.himss.org/ASP/topics_nursingInformatics.asp
  • Chao, S., Anderson, K., & Hernandez, l. (2009). Toward health equity and patient-centeredness: Integrating health literacy, disparities reduction, and quality improvement: Workshop Summary (2009). Washington, DC: The National Academies Press. Retrieved from http://www.nap.edu/catalog.php?record_id=12502
  • The Joint Commission. (n.d.). National patient safety goals. Retrieved from http://www.jointcommission.org/standards_information/npsgs.aspx
  • (n.d.). Quality and patient safety. Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/index.html
  • AONE. (n.d.). Retrieved from http://www.aone.org/
  • National Academies: Health and Medicine Division. http://www.nationalacademies.org/hmd/
  • American Nurses Association. (n.d.). NursingWorld. Retrieved from http://nursingworld.org/
  • American College of Healthcare Executives. (n.d.). Retrieved from http://www.ache.org/
  • Institute for Healthcare Improvemen (n.d.). Retrieved from http://www.ihi.org/Pages/default.aspx
  • S. Department of Health & Human Services. (n.d.). HHS.Gov. Retrieved from http://www.hhs.gov/
  • National Institutes of Health. (n.d.) Retrieved from http://www.nih.gov/
  • NCQA. (n.d.) Retrieved from http://www.ncqa.org/
  • QSEN Institute. (n.d.). Retrieved from http://www.qsen.org/
  • Agency for Healthcare Research and Quality. (2009). Hospital survey on safety culture: 2009 comparative database report. Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/2009/hospsurv091.pdf
  • Hospital Safety Score. (n.d.). Retrieved from http://www.hospitalsafetyscore.org/

Bookstore Resources

The resources listed below are relevant to the topics and assessments in this course and are not required. Unless noted otherwise, these materials are available for purchase from the Capella University Bookstore. When searching the bookstore, be sure to look for the Course ID with the specific –FP (FlexPath) course designation.

  • Huber, D. L. (2014). Leadership and nursing care management (5th ed.). Maryland Heights, MO: W. B. Saunders.
    • Chapter 4.
    • Chapter 16.
    • Chapter 17.
    • Chapter 18.






Assessment Instructions


Refer to the Capella library and the Internet for supplemental resources to help you complete this assessment, a safety score improvement plan.

Consider the hospital-acquired conditions that are not reimbursed for under Medicare/Medicaid. Among these conditions are specific safety issues such as infections, falls, medication errors, and other safety concerns that could have been prevented or alleviated with the use of evidence-based guidelines. Hospital Safety Score, an independent nonprofit organization, uses national performance measures to determine the safety score for hospitals in the United States. The Hospital Safety Score Web site and other online resources provide hospital safety scores to the public.

Read the scenario below:


As the manager of a unit, you have been advised by the patient safety office of an alarming increase in the hospital safety score for your unit. This is a very serious public relations matter because patient safety data is public information. It is also a financial crisis because the organization stands to lose a significant amount of reimbursement money from Medicare and Medicaid unless the source of the problem can be identified and corrected. You are required to submit a safety score improvement plan to the organization’s leadership and the patient safety office.

Select a specific patient safety goal that has been identified by an organization, or one that is widely regarded in the nursing profession as relevant to quality patient care delivery, such as patient falls, infection rates, catheter-induced urinary infections, IV infections, et cetera.

Deliverable: Safety Score Improvement Plan

Develop a 3–5 page safety score improvement plan.

  • Identify the health care setting and nursing unit of your choicein the title of the mitigation plan. For example, “Safety Score Improvement Plan for XYZ Rehabilitation Center.”
  • You may choose to use information on a patient safety issue for the organization in which you currently work, or search for information from a setting you are familiar with, perhaps from your clinical work.
    • Demonstrate systems theory and systems thinking as you develop your recommendations.

Organize your report with these headings:

Study of Factors
  • Identify a patient safety issue.
  • Describe the influence of nursing leadership in driving the needed changes.
  • Apply systems thinking to explain how current policies and procedures may affect a safety issue.
  • Recommend an evidence-based strategy to improve the safety issue.
  • Explain a strategy to collect information about the safety concern.
    • How would you determine the sources of the problem?
  • Explain a plan to implement a recommendation and monitor outcomes.
    • What quality indicators will you use?
    • How will you monitor outcomes?
    • Will policies or procedures need to be changed?
    • Will nursing staff need training?
    • What tools will you need to do this?
Additional Requirements
  • Written communication: Written communication should be free of errors that detract from the overall message.
  • APA formatting: Resources and in-text citations should be formatted according to current APA style and formatting.
  • Length: The plan should be 3–5 pages.
  • Font and font size: Times New Roman, 12 point, double-spaced.
  • Number of resources: Use a minimum of three peer-reviewed resources.







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