Assessment 3 Issue Analysis and Leadership Action Plan

Importance and Features of Continuous Quality Improvement (CQI) Depending on the organization, continuous quality improvement (CQI) programs differ in size and scope. Likewise, they may be called a variety of names, such as quality and performance improvement, quality management, regulatory compliance, and quality improvement (Sollecito & Johnson, 2013). Despite the progress in CQI, health care quality improvement requires greater continued efforts due to the health care environment’s vibrant and complex nature.

CQI is a “structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations” (Sollecito & Johnson, 2013, p. 4). A common set of features characterizes CQI, which includes the following (Sollecito & Johnson, 2013, pp. 4–5):

• A link to key elements of the organization’s strategic plan. • A quality council made up of the institution’s top leadership. • Training programs for personnel. • Mechanisms for selecting improvement opportunities. • Formation of process improvement teams. • Staff support for process analysis and redesign. • Personnel policies that motivate and support staff participation in process

improvement. • Application of the most current and rigorous techniques of the scientific method

and statistical process control.

For CQI to flourish within an organization, it needs to be rooted in the organization’s culture. Culture is the combination of shared attitudes, values, competencies, goals and behaviors that define the organization’s practices (Silva, Barbosa, Padilha, & Malik, 2016). All stakeholders within the organization are responsible for health care quality and safety.

Leaders who wish to create a safety culture must first assess their organization’s readiness to implement the necessary safety practices. In addition, the Agency for Healthcare Research and Quality (AHRQ) has created culture assessment tools that allow organizations to identify benchmarks to establish a culture of safety in comparison to similar hospitals or hospital units. The fair and just culture concept encourages leaders to ask what happened instead of who made the error (Pelletier & Beaudin, 2018). Additionally, a fair and just culture aids in making the system safer. Stakeholders understand errors are inevitable and that all errors need to be reported, even when events may not cause patient harm (Pelletier & Beaudin, 2018).

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Pelletier and Beaudin emphasize how critical it is for leaders to assume responsibility for driving improved patient safety practices throughout the organization (2018). To demonstrate this, leaders need to incorporate health care safety practices as a part of the organization’s strategic direction and to develop goals to guarantee adoption and measurement of safe practices. The governing body or board of directors is responsible for endorsing and upholding quality of care and preserving safety. Quality oversight is recognized more clearly as a core fiduciary duty relating not only to financial health and reputation but to safety and quality of care (Pelletier & Beaudin, 2018).

References

Pelletier, L. R., & Beaudin, C. L. (2018) HQ solutions: Resource for the healthcare quality professional (4th ed.). Philadelphia, PA: Wolters Kluwer.

Silva, Natasha Dejigov Monteiro da, Barbosa, A. P., Padilha, K. G., & Malik, A. M. (2016). Patient safety in organizational culture as perceived by leaderships of hospital institutions with different types of administration. Revista Da Escola De Enfermagem Da U S P, 50(3), 490-497.

Sollecito, W. A., & Johnson, J. K. (2013). Mclaughlin and Kaluzny’s continuous quality improvement in health care (4th ed.). Burlington, MA: Jones & Bartlett Learning.