You are an Assistant Administrator at Best Start Health Care System. The organization is a mid-sized teaching hospital with an affiliation to a regional medical school. Recently, you attended a meeting with the hospital's Chief Operating Officer (COO), the Director of Quality Management [your immediate manager], Director of Nursing Services, Manager of System Analytics, Assistant Director of Pharmacy, and the Chief Medical Officer to discuss a recent internal audit. This audit identified two key areas that significantly underperformed: ? Hospital - Acquired Infection Rates ? Medication Errors During the meeting it was revealed that the Best Start Health Care System has an anticipated accreditation inspection from Joint Commission within the next twelve to eighteen months. The Manager of System Analysis shares data associated with each of the two areas in question. The Chief Medical Officer states that each year in July new physician Fellows or Residents start yearly rotation, and the on-boarding new Fellows is resource consuming. The Director of Nursing Services voices their opinion that nursing staffing is a challenge during the Christmas Holidays, and as a result the usage of travelling nurses at the institution increases by 15% each December. Based upon the impending inspection it was noted a plan of action needed to be established. The group's decided the following action(s) needed to be taken: ? Meet in thirty days with a general plan of action. ? Assign a point person to develop a list of recommendations, and educate the team on the importance of Continuous Quality Improvement within a health system ? The Director of Quality Manager and his team will lead the effort Post-meeting, the Director of Quality Management and you huddle to discuss the actions that need to be taken. S/he designates you as project leader. As project leader you will generate

Appendix A Report Infections for the year 20XX Surgical Types Number of Number of Frequency National Goals Infections Surgeries Neurological 10 200 5.00% 2.00% Orthopedic 15 100 15.00% 5.00% Cardiovascular 50 2,000 2.50% 1.00% Plastic 25 800 3.13% 5.00% Urological 15 500 3.00% 2.00% General Surgery 75 5.000 1.50% 1.00%Appendix B Medication Errors by Month Month Errors cbar UCL LCL Jan 6 9.17 14.00 1.00 Feb UI 9.17 14.00 1.00 Mar 9.17 14.00 1.00 Apr 3 9.17 14.00 1.00 May 9.17 14.00 1.00 Jun 9 9.17 14.00 1.00 Jul 16 9.17 14.00 1.00 Aug 9.17 14.00 1.00 Sep 12 9.17 14.00 1.00 Oct 8 9.17 14.00 1.00 Nov 7 9.17 14.00 1.00 Dec 22 9.17 14.00 1.00 Total 110 cbar 9.17 UCL 14.00 LCL 1.00Errors per Sample 25 20 15 10 5 0 Jan Feb Mar Apr May Jun Appendix C c Chart Jul Aug Sep Oct Nov Dec .cbar LCLC Errors UCLCAppendix D Medication Errors By Departments Department Total Error Medical Descriptions Medication Types Medical Surgery 33 Insulin 44 Emergency Department 7 Pain Meds 60 ICU 6 Sleep Meds 6 Cardiac Post-Surgery 19 Plastic Surgery 45 Total 110 110