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Action Plan

Module 4: Assignment 2: Instructions for Action Plan
1). Format: Your action plan is to be a Microsoft Word document of around 5 – 7 double-spaced pages. Include a cover page which will not count toward the page limit. The reference page will count toward the page limit. Use the following outline to organize your paper and use the headings for each section of the paper. These headings are used for grading purposes and follow APA 6th Ed.
Patient Safety/Quality Improvement Statement and Chosen Cause that will Drive Improvement This Heading is first level and is Centered, Boldface, Uppercase and Lowercase Headings (APA, 6th Ed.)
Current Knowledge of the Patient Safety Concern/Quality Improvement Issue (State and National Context) This Heading is first level and is Centered, Boldface, Uppercase and Lowercase Headings (APA, 6th Ed.)
Proposed Improvement Plan and Rationale This Heading is first level and is Centered, Boldface, Uppercase and Lowercase Headings (APA, 6th Ed,)
Proposed Improvement Intervention Proposed Implementation Plan Proposed Measures to Evaluate Effectiveness These Headings are second level and are Left-aligned, Boldface, Uppercase and Lowercase Heading (APA, 6th Ed.)
References This Heading is Centered, Uppercase and Lowercase Headings (see reference format in APA, 6th Ed,)
2.) Content of Action Plan:
Identify the patient safety concern/quality improvement issue from your RCA. Identify one cause that will drive improvement – what cause have you selected from your RCA; what are you trying to improve? Why did your select this problem? (no more than 1 paragraph; no citations required; do not identify agency, its location or persons involved)•
Discuss current knowledge of the patient safety concern/quality improvement issue(state and national context) (no more than 2 – 4 paragraphs; citations required) o Provide information related to current knowledge related to the concern/issue – what is known about the concern/issue? What does the evidence say? Is your concern/issue a national quality or safety priority or goal of the National Quality Forum (NQF), The Joint Commission (JC), the National Quality Assurance Committee (NCQA), The Agency for Healthcare Research and Quality\’s (AHRQ) or Healthy People 2020? Is your concern/issue one of the Harms (AHA/HRET•
HEN) that your state is working on? (See some examples of sources for this information below) o Provide information related to concern/issue: current data (see some examples of sources below for this information), i.e. mortality rates, cost, etc.; What benchmarks must organizations achieve? Are there mandatory consequences if these benchmarks are not achieved? o Is the “cause” that you chose discussed as a primary cause of the patient safety concern or quality improvement issue? Provide an explanation.
Some examples of Sources: a. National Quality Forum – www.qualityforum.org Is your issue a “NQF endorsed national voluntary consensus standard for nurse sensitive care”? Go into the NQF website b. Joint Commission www.jointcommission.org Is your issue a “national patient safety goal”? Go into the JC website, click on patient safety, then national patient safety goals, then on your desired setting(s) c. National Quality Assurance Committee www.ncqa.org
Is your issue one of the problems tracked in the Healthcare Effectiveness Data and Information Set (HEDIS) for health plans? Go into the NCQA website, click on HEDIS and Quality Measurement, click on “more” information or search HEDIS Measures
d. The Agency for Healthcare Research and Quality\’s (AHRQ) http://www.ahrq.gov/ Is your issue a quality and patient safety concern, or a prevention and chronic care issue? Go to the AHRQ website and click on For Professionals.
e. Healthy People 2020 www.healthypeople.gov Is your issue a “leading health indicator”? Go into the Healthy People website, click on leading health indicators
f. Harms (AHA/HRET HEN) http://hret-hen.org/ Is your issue one of the Harms? Find your state’s hospital association and its information related to Harms. For the state of Indiana: https://www.ihaconnect.org/Quality-PatientSafety/Pages/Quality-and-Patient-Safety.aspx

Proposed Improvement Plan and Rationale – Identify the change you want to accomplish? What is your goal? (This plan is to be supported by evidence. Describe the evidence and provide source, i.e., an evidence-based article relevant to your plan, or clinical practice guidelines, or toolkit from a national or state agency, such as those sources cited above, etc. This entire section should be no more than 2 – 3 pages, citations required)•
Describe the actual improvement intervention you propose. Be specific. Think about the hierarchy of solutions that was discussed in the Module 4 Power Point. Are your proposed interventions weak, intermediate or strong?•
Describe how you plan to implement your improvement process to increase its chances of success. Who needs to be involved in the implementation of your improvement? Identify whether pilot testing of the planned improvement should be conducted and provide details. Improvements to reduce risk should ultimately be implemented in all areas where applicable, not just where the event occurred. Discuss where the improvements will be implemented initially and then pushed out.•
Describe how you will measure to evaluate whether or not your proposed improvement is effective. What is the target? What data will you collect to show that your change made a difference? How will you collect the data? Discuss how the selected measure will provide data that will permit assessment of the effectiveness of the action. To whom will you share the data? Identify and describe the measurable outcome.•
3. Submit Assignment to the Module 4 Blackboard Assignment 2 submission area by end of day Sunday of Module 4.

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