Assignment Prompt & Instructions
– ## Module5.docx
**## Module5.docx**
Module 5: Quality Improvement
This module is all about Quality Improvement. "Quality improvement is the framework used to systematically improve care. Quality improvement seeks to standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients, healthcare systems, and organizations" (U.S. Centers for Medicare & Medicaid Services, n.d.). It is incredibly important that we strive to understand the need for quality improvement, and that we implement it into practice.
You will also complete and submit your Signature Assignment (SA) this week. The SA is worth 40% of your course grade and you MUST score a 78% or higher on it to pass the entire course. It is very important to put time and focused energy into your work for this assignment.
_Continuous Improvement Pictures, images and stock photos_. iStock. (n.d.). https://www.istockphoto.com/photos/continuous-improvement
**Course Objectives:**
3. Summarize the potential and actual impact of patient safety initiatives and regulations.
5. Apply quality improvement principles in care delivery
**Module Objectives:**
1. Create a framework for quality, safe, patient centered care. CO: 5
2. Appraise the components of a root cause analysis. CO: 3
**Required Chapter Readings and Resources:**
Chapter 11: Quality Improvement Essentials
Chapter 14: Quality Improvement and Project Management
**Reference:**
U.S. Centers for Medicare & Medicaid Services. (n.d.).
_Quality Measurement and Quality Improvement_. CMS.gov.
[https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/mms/quality-measure-and-quality-improvement-#:~:text=Quality%20improvement%20is%20the%20framework,%2C%20healthcare%20systems%2C%20and%20organizationsLinks to an external site.](https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/mms/quality-measure-and-quality-improvement-).
**Required Assignment:**
[**Root Cause Analysis PowerPoint or Padlet Assignment Based on a Sentinel Event Case Study**](https://nku.instructure.com/courses/82359/assignments/1406785?wrap=1)
**Signature Assignment Lecture:**
**he Signature Assignment (SA):**
The SA is worth 40% of your course grade and you MUST score a 78% or higher on it to pass the entire course. It is very important to put time and focused energy into your work for this assignment.
Please read the following articles and watch the video about the RaDonda Vaught Case. Then continue to do your own research on the aspects of this case directly related to nursing responsiblity and legalities. I encourage you to spend considerable time researching this case more in-depth outside of the provided resources here.
**Complete a Root Cause Analysis based on this case:**
1.
1. Explain what a Root Cause Analysis is and the purpose of using one for your facility.
2. What were the major issues and contributing factors that led to the incident in the RaDonda Vaught Case? What occurred based on facts shared in these resources?
1. Please include all details surrounding this case. Explain the situation and causes. Speak to issues that may have led to distraction, protection of the hospital, nursing responsibilities, and anything else you feel is pertinent to share about this case.
3. What, how, and why did this incident occur?
4. What was this nurse charged with? Do you think this was fair after completing your research?
5. What are opportunities and/or plans of improvement to prevent similar situations in happen in the future? Identify the best evidence(s) to support policy development related to this issue.
6. Please also share your feelings and concerns as a result of studying this particular case. How can you better protect your patients and yourself?
7. Create a safe medication administration flyer or announcement to display in your facility. Please include a picture of your flyer or announcement to include in this presentation.
*Your presentation should have 16-20 slides for a PowerPoint Presentation (or 8-10 sections if you are using a Padlet). Use at least three scholarly references within 5 years. Include a title page and reference page (these are not included in the slide or section count).
*You must use color, design, pictures/art to create a visually pleasing presentation. You want this to be interesting to your audience.
**Video and Articles to Support this Assignment:**
[https://www.youtube.com/watch?v=69hdAy6oay8Links to an external site.](https://www.youtube.com/watch?v=69hdAy6oay8)
[https://www.psqh.com/analysis/lessons-learned-from-the-radonda-vaught-case/Links to an external site.](https://www.psqh.com/analysis/lessons-learned-from-the-radonda-vaught-case/)
[https://www.tennessean.com/story/news/crime/2022/05/13/radonda-vaught-sentenced-vanderbilt-nurse/9717529002/Links to an external site.](https://www.tennessean.com/story/news/crime/2022/05/13/radonda-vaught-sentenced-vanderbilt-nurse/9717529002/)
If you decide to use a Padlet, here is the link:
[https://padlet.com/Links to an external site.](https://padlet.com/)
COs: 3 & 5
MO: 1, 2
**References:**
Gluck, F., & Timms, M. (2022, May 13).
_Radonda Vaught sentenced to three years probation on a diverted sentence, could see record wiped_. The Tennessean. Retrieved March 3, 2023, from https://www.tennessean.com/story/news/crime/2022/05/13/radonda-vaught-sentenced-vanderbilt-nurse/9717529002/
Nightline. (n.d.-a).
_Former nurse speaks out after sentencing in fatal drug error_. YouTube. https://www.youtube.com/watch?v=69hdAy6oay8
Ramsay, M. (2022, June 22).
_Lessons learned from the Radonda Vaught case_. Patient Safety & Quality Healthcare. Retrieved March 3, 2023, from https://www.psqh.com/analysis/lessons-learned-from-the-radonda-vaught-case/
Rubric
**Root Cause Analysis Presentation**
| | | |
| — | — | — |
| Root Cause Analysis Presentation |
| **Criteria** | **Ratings** | **Pts** |
| This criterion is linked to a Learning OutcomeBackground, Root Cause Analysis, Contributing Factors and Facts<br>The student explained what a Root Cause Analysis is and the purpose of its usage, the major issues and contributing factors that led to the incident in the RaDonda Vaught Case, and what occurred based on facts shared in these resources. The student included all details surrounding the case, and explained the situation and causes. | **27 ptsFull Marks** The student explained what a Root Cause Analysis is and the purpose of its usage, the major issues and contributing factors that led to the incident in the RaDonda Vaught Case, and what occurred based on facts shared in these resources. The student included all details surrounding the case, and explained the situation and causes.<br> <br>**14 ptsPartially Meets** The student explained what a Root Cause Analysis is and the purpose of its usage, but left off major issues and contributing factors that led to the incident in the RaDonda Vaught Case, and what occurred based on facts shared. The student provided a vague description of details surrounding the case, situation and causes.<br> <br>**0 ptsNo Marks** Little to no explanation of the root cause analysis, contributing factors, and/or issues surrounding this case were provided. | 27 pts |
| This criterion is linked to a Learning OutcomeDetails that led to Distraction, Nursing and Hospital Responsibilities, Pertinent Case Data, What, How, Why of this Incident<br>The student described the issues that may have led to distraction, protection of the hospital, nursing responsibilities, and anything else that was pertinent to share about the case.<br>What, how, and why did this incident occur? | **27 ptsFull Marks** The student described the issues that may have led to distraction, protection of the hospital, nursing responsibilities, and anything else that was pertinent to share about the case. What, how, and why did this incident occur?<br> <br>**14 ptsPartially Meets** The student provided a vague description of the issues that may have led to distraction, protection of the hospital, nursing responsibilities, and anything else that was pertinent to share about the case. Little description of what, how, and why this incident occurred was provided.<br> <br>**0 ptsNo Marks** Little to no explanation of the nursing and hospital responsibilities, distractions, pertinent case data, or details were noted. | 27 pts |
| This criterion is linked to a Learning OutcomeCharges, Opportunities for Future Improvement and Prevention<br>The student presented the charges brought against the nurse and whether or not the student feels the charges were fair.<br>Opportunities and/or plans of improvement to prevent similar situations in happen in the future were explained in detail. The student identified the best evidence(s) to support policy development related to this issue. The student created a safe medication administration flyer or announcement and provided proof of the display in his/her facility within this presentation. | **26 ptsFull Marks** The student presented the charges brought against the nurse and whether or not the student feels the charges were fair. Opportunities and/or plans of improvement to prevent similar situations in happen in the future were explained in detail. There was a deep explanation of health policy to support change related to this case. The student created a safe medication administration flyer or announcement and provided proof of the display in his/her facility within this presentation.<br> <br>**13 ptsPartially Meets** A vague description of the charges brought against the nurse and whether or not the student feels the charges were fair were presented. Opportunities and/or plans of improvement to prevent similar situations in happen in the future were mentioned, but vague in detail. There was a vague mention of health policy related to this issue. The use of a flyer or announcement about safe medication administration was mentioned, but not seen in the presentation.<br> <br>**0 ptsNo Marks** Little to no description of the charges brought against the nurse and whether or not the student feels the charges were fair were presented. No mention of plans of improvement to prevent similar situations in happen in the future or health policy related to this topic were mentioned. No mention of a safe medication administration flyer or announcement was noted. | 26 pts |
| This criterion is linked to a Learning OutcomeTimeliness, Quality of Presentation, Slide Count, APA Formatting<br>The student submitted this assignment on time. It was visually pleasing with clean slides design and usage of pictures/art and color and design to support. The presentation was 16-20 slides for a PowerPoint Presentation (or 8-10 sections if you are using a Padlet). At least three scholarly references within 5 years were used. A title page and reference page were used but not included in the slide or section count. APA 7th Edition formatting was used throughout. Slides had citations at the bottom when references were used. | **20 ptsFull Marks** The student submitted this assignment on time. It was visually pleasing with clean slides design and usage of pictures/art and color and design to support. The presentation was 16-20 slides for a PowerPoint Presentation (or 8-10 sections if you are using a Padlet). At least three scholarly references within 5 years were used. A title page and reference page were used but not included in the slide or section count. APA 7th Edition formatting was used throughout. Slides had citations at the bottom when references were used.<br> <br>**10 ptsPartially Meets** Either the student did not submit this assignment on time, it was not visually pleasing, the presentation was outside of the 16-20 slides count, less than three scholarly references within 5 years were used, a lack of APA 7th Edition formatting was noted.<br> <br>**0 ptsNo Marks** This assignment had APA errors throughout, was well under the slide count, no references were noted, or the submission was not a presentation in design. | 20 pts |
Total Points: 100
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**## Module5.docx**
Module 5: Quality Improvement
This module is all about Quality Improvement. "Quality improvement is the framework used to systematically improve care. Quality improvement seeks to standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients, healthcare systems, and organizations" (U.S. Centers for Medicare & Medicaid Services, n.d.). It is incredibly important that we strive to understand the need for quality improvement, and that we implement it into practice.
You will also complete and submit your Signature Assignment (SA) this week. The SA is worth 40% of your course grade and you MUST score a 78% or higher on it to pass the entire course. It is very important to put time and focused energy into your work for this assignment.
_Continuous Improvement Pictures, images and stock photos_. iStock. (n.d.). https://www.istockphoto.com/photos/continuous-improvement
**Course Objectives:**
3. Summarize the potential and actual impact of patient safety initiatives and regulations.
5. Apply quality improvement principles in care delivery
**Module Objectives:**
1. Create a framework for quality, safe, patient centered care. CO: 5
2. Appraise the components of a root cause analysis. CO: 3
**Required Chapter Readings and Resources:**
Chapter 11: Quality Improvement Essentials
Chapter 14: Quality Improvement and Project Management
**Reference:**
U.S. Centers for Medicare & Medicaid Services. (n.d.).
_Quality Measurement and Quality Improvement_. CMS.gov.
[https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/mms/quality-measure-and-quality-improvement-#:~:text=Quality%20improvement%20is%20the%20framework,%2C%20healthcare%20systems%2C%20and%20organizationsLinks to an external site.](https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/mms/quality-measure-and-quality-improvement-).
**Required Assignment:**
[**Root Cause Analysis PowerPoint or Padlet Assignment Based on a Sentinel Event Case Study**](https://nku.instructure.com/courses/82359/assignments/1406785?wrap=1)
**Signature Assignment Lecture:**
**he Signature Assignment (SA):**
The SA is worth 40% of your course grade and you MUST score a 78% or higher on it to pass the entire course. It is very important to put time and focused energy into your work for this assignment.
Please read the following articles and watch the video about the RaDonda Vaught Case. Then continue to do your own research on the aspects of this case directly related to nursing responsiblity and legalities. I encourage you to spend considerable time researching this case more in-depth outside of the provided resources here.
**Complete a Root Cause Analysis based on this case:**
1.
1. Explain what a Root Cause Analysis is and the purpose of using one for your facility.
2. What were the major issues and contributing factors that led to the incident in the RaDonda Vaught Case? What occurred based on facts shared in these resources?
1. Please include all details surrounding this case. Explain the situation and causes. Speak to issues that may have led to distraction, protection of the hospital, nursing responsibilities, and anything else you feel is pertinent to share about this case.
3. What, how, and why did this incident occur?
4. What was this nurse charged with? Do you think this was fair after completing your research?
5. What are opportunities and/or plans of improvement to prevent similar situations in happen in the future? Identify the best evidence(s) to support policy development related to this issue.
6. Please also share your feelings and concerns as a result of studying this particular case. How can you better protect your patients and yourself?
7. Create a safe medication administration flyer or announcement to display in your facility. Please include a picture of your flyer or announcement to include in this presentation.
*Your presentation should have 16-20 slides for a PowerPoint Presentation (or 8-10 sections if you are using a Padlet). Use at least three scholarly references within 5 years. Include a title page and reference page (these are not included in the slide or section count).
*You must use color, design, pictures/art to create a visually pleasing presentation. You want this to be interesting to your audience.
**Video and Articles to Support this Assignment:**
[https://www.youtube.com/watch?v=69hdAy6oay8Links to an external site.](https://www.youtube.com/watch?v=69hdAy6oay8)
[https://www.psqh.com/analysis/lessons-learned-from-the-radonda-vaught-case/Links to an external site.](https://www.psqh.com/analysis/lessons-learned-from-the-radonda-vaught-case/)
[https://www.tennessean.com/story/news/crime/2022/05/13/radonda-vaught-sentenced-vanderbilt-nurse/9717529002/Links to an external site.](https://www.tennessean.com/story/news/crime/2022/05/13/radonda-vaught-sentenced-vanderbilt-nurse/9717529002/)
If you decide to use a Padlet, here is the link:
[https://padlet.com/Links to an external site.](https://padlet.com/)
COs: 3 & 5
MO: 1, 2
**References:**
Gluck, F., & Timms, M. (2022, May 13).
_Radonda Vaught sentenced to three years probation on a diverted sentence, could see record wiped_. The Tennessean. Retrieved March 3, 2023, from https://www.tennessean.com/story/news/crime/2022/05/13/radonda-vaught-sentenced-vanderbilt-nurse/9717529002/
Nightline. (n.d.-a).
_Former nurse speaks out after sentencing in fatal drug error_. YouTube. https://www.youtube.com/watch?v=69hdAy6oay8
Ramsay, M. (2022, June 22).
_Lessons learned from the Radonda Vaught case_. Patient Safety & Quality Healthcare. Retrieved March 3, 2023, from https://www.psqh.com/analysis/lessons-learned-from-the-radonda-vaught-case/
Rubric
**Root Cause Analysis Presentation**
| | | |
| — | — | — |
| Root Cause Analysis Presentation |
| **Criteria** | **Ratings** | **Pts** |
| This criterion is linked to a Learning OutcomeBackground, Root Cause Analysis, Contributing Factors and Facts<br>The student explained what a Root Cause Analysis is and the purpose of its usage, the major issues and contributing factors that led to the incident in the RaDonda Vaught Case, and what occurred based on facts shared in these resources. The student included all details surrounding the case, and explained the situation and causes. | **27 ptsFull Marks** The student explained what a Root Cause Analysis is and the purpose of its usage, the major issues and contributing factors that led to the incident in the RaDonda Vaught Case, and what occurred based on facts shared in these resources. The student included all details surrounding the case, and explained the situation and causes.<br> <br>**14 ptsPartially Meets** The student explained what a Root Cause Analysis is and the purpose of its usage, but left off major issues and contributing factors that led to the incident in the RaDonda Vaught Case, and what occurred based on facts shared. The student provided a vague description of details surrounding the case, situation and causes.<br> <br>**0 ptsNo Marks** Little to no explanation of the root cause analysis, contributing factors, and/or issues surrounding this case were provided. | 27 pts |
| This criterion is linked to a Learning OutcomeDetails that led to Distraction, Nursing and Hospital Responsibilities, Pertinent Case Data, What, How, Why of this Incident<br>The student described the issues that may have led to distraction, protection of the hospital, nursing responsibilities, and anything else that was pertinent to share about the case.<br>What, how, and why did this incident occur? | **27 ptsFull Marks** The student described the issues that may have led to distraction, protection of the hospital, nursing responsibilities, and anything else that was pertinent to share about the case. What, how, and why did this incident occur?<br> <br>**14 ptsPartially Meets** The student provided a vague description of the issues that may have led to distraction, protection of the hospital, nursing responsibilities, and anything else that was pertinent to share about the case. Little description of what, how, and why this incident occurred was provided.<br> <br>**0 ptsNo Marks** Little to no explanation of the nursing and hospital responsibilities, distractions, pertinent case data, or details were noted. | 27 pts |
| This criterion is linked to a Learning OutcomeCharges, Opportunities for Future Improvement and Prevention<br>The student presented the charges brought against the nurse and whether or not the student feels the charges were fair.<br>Opportunities and/or plans of improvement to prevent similar situations in happen in the future were explained in detail. The student identified the best evidence(s) to support policy development related to this issue. The student created a safe medication administration flyer or announcement and provided proof of the display in his/her facility within this presentation. | **26 ptsFull Marks** The student presented the charges brought against the nurse and whether or not the student feels the charges were fair. Opportunities and/or plans of improvement to prevent similar situations in happen in the future were explained in detail. There was a deep explanation of health policy to support change related to this case. The student created a safe medication administration flyer or announcement and provided proof of the display in his/her facility within this presentation.<br> <br>**13 ptsPartially Meets** A vague description of the charges brought against the nurse and whether or not the student feels the charges were fair were presented. Opportunities and/or plans of improvement to prevent similar situations in happen in the future were mentioned, but vague in detail. There was a vague mention of health policy related to this issue. The use of a flyer or announcement about safe medication administration was mentioned, but not seen in the presentation.<br> <br>**0 ptsNo Marks** Little to no description of the charges brought against the nurse and whether or not the student feels the charges were fair were presented. No mention of plans of improvement to prevent similar situations in happen in the future or health policy related to this topic were mentioned. No mention of a safe medication administration flyer or announcement was noted. | 26 pts |
| This criterion is linked to a Learning OutcomeTimeliness, Quality of Presentation, Slide Count, APA Formatting<br>The student submitted this assignment on time. It was visually pleasing with clean slides design and usage of pictures/art and color and design to support. The presentation was 16-20 slides for a PowerPoint Presentation (or 8-10 sections if you are using a Padlet). At least three scholarly references within 5 years were used. A title page and reference page were used but not included in the slide or section count. APA 7th Edition formatting was used throughout. Slides had citations at the bottom when references were used. | **20 ptsFull Marks** The student submitted this assignment on time. It was visually pleasing with clean slides design and usage of pictures/art and color and design to support. The presentation was 16-20 slides for a PowerPoint Presentation (or 8-10 sections if you are using a Padlet). At least three scholarly references within 5 years were used. A title page and reference page were used but not included in the slide or section count. APA 7th Edition formatting was used throughout. Slides had citations at the bottom when references were used.<br> <br>**10 ptsPartially Meets** Either the student did not submit this assignment on time, it was not visually pleasing, the presentation was outside of the 16-20 slides count, less than three scholarly references within 5 years were used, a lack of APA 7th Edition formatting was noted.<br> <br>**0 ptsNo Marks** This assignment had APA errors throughout, was well under the slide count, no references were noted, or the submission was not a presentation in design. | 20 pts |
Total Points: 100
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