Write an analysis and leadership action plan for the issue you selected that will enable you to address the issue on an organization-wide basis. Please make sure to include all of the following headings and answer all of the questions underneath each heading.

• Introduction: Issue Summary
  • How would you summarize the key elements of the incident that occurred?
  • What is your goal in addressing the issue?
  • Which 2-3 key items will be your focus? For example, you may elect to focus on nursing staffing levels if being short-staffed in nursing is contributing to compromises to patient safety.
• Culture: Explain what culture is and why it is a critical priority for safety and quality, providing at least two evidence-based strategies for cultivating a culture of safety.
  • What is culture?
  • Why is culture a critical organizational priority for safety and quality?
  • What do you know about the existing organizational culture, based on the knowledge you have about the selected issue?
  • What are some of the evidence-based strategies you are considering that could be employed to cultivate a culture of safety?
• IHI Triple Aim: Apply the IHI Triple Aim to develop a health care leadership strategy that focuses on optimizing health care system performance.
  • What is the IHI Triple AIM?
  • How does the IHI Triple Aim apply to this specific incident?
  • What IHI Triple Aim elements will you incorporate into your organizational improvement strategy?
• Leadership and Collaboration: Propose evidence-based leadership and collaboration strategies to enlist the aid of key organizational leaders in establishing a safety and quality culture.
  • Which key departments need to be directly involved with the corrective action process?
  • What is your rationale for selecting these departments? For example, you may want to involve nursing because many of errors involve nurses and obtaining their buy-in is critical to achieving the organizational priority.
  • Which specific senior leader, front-line staff member, and clinical expert will you include in your action plan and hold accountable for implementation?
  • What are the implications of not engaging with all departments toward making safety and quality top of mind?
  • How might you involve other departments in addressing the specific issue and the cultural issue?
  • Which specific leaders within the organization could assist you in addressing this issue and in making patient safety and quality top of mind throughout the organization? Examples for you to consider include the chief nursing officer, the chief medical officer, the patient safety officer, et cetera.
  • What role do you expect these leaders to play in addressing the specific issue and the issue of culture?
  • What best practices would you employ to enlist their aid in the improvement effort?
• Leadership Action Plan: Create an evidence-based action plan that includes leadership strategies to establish a safety and quality culture.
  • What are three evidence-based (supported by current literature) leadership strategies you recommend that would help to solve the incident that occurred?
  • What are three evidence-based best practices you recommend to address the issue on an organizational level?
• Opportunities to Enlist Governing Board: Determine opportunities to enlist the governing board's aid in fostering a fair and just culture.
  • What role does the organization's governing board have in terms of quality and safety in the organization?
  • How could you enlist the governing board's aid in your improvement initiative?
  • What additional information could you provide them to increase their involvement in the organization's safety and quality improvement efforts?
• Conclusion
  • How will you summarize your analysis of the incident and your leadership action plan?