Health Care Administration Capstone

Executive Summary to CEO
[WLOs: 1, 2, 3] [CLOs: 1, 2, 3, 4, 5]

Prior to beginning work on this assignment,

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Read the Writing Center Writing an Executive Summary
(Links to an external site.)
Read the CMHA-CEI Policies and Procedures Manual
(Links to an external site.)
Read the Continuous Quality Improvement (CQI) Strategies to Optimize Your Practice
(Links to an external site.)
Read the Medical Errors Nursing CE Course
(Links to an external site.)
Read the QUERI – Quality Enhancement Research Initiative
(Links to an external site.)
Read the Sentinel Events CY2018: Annual Report to the Maine State Legislature
(Links to an external site.)
Read the Six Steps for Successful Incident Investigation
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Read the Tools: Cause and Effect Diagram
(Links to an external site.)
Watch the following videos that describe the details included in a Fishbone Diagram
Whiteboard: Cause and Effect Diagram
(Links to an external site.)
, by Institute of Healthcare Improvement
Quality (Part 2: Ishikawa Diagram)
(Links to an external site.)
, by Infinity MFG
Read the Using Quality Improvement Methods for Evaluating Health Care
(Links to an external site.)

For this written assignment, you will prepare an executive summary for the CEO using the same sentinel event addressed earlier in the course. This report will be prepared for the CEO of the organization where the sentinel event occurred. The CEO is then required to provide details from the executive summary to the Board of Trustees and other stakeholders in the organization to identify the next steps of managing the sentinel event.

Managing a sentinel event usually consists of the following steps: immediate action, planning the investigation, data collection, data analysis, corrective action plan, and reporting to accreditation agencies. For this assignment, you will focus on the parts below to develop a cohesive plan to address the sentinel event. Address the following in the Executive Summary to CEO template.

Part 1: The Sentinel Event

Summarize the facts related to the sentinel event:
Description of the event
Staff involved
Discuss the timeline events from initiation of the error through the resolution (will vary depending upon the sentinel event):
When and/or where did the error occur?
When was it detected?
When was it reported and to whom?
Evaluate procedural errors:
Identify the point in time when the error should have been detected before it occurred.
What part of the process or procedure was missed that contributed to the sentinel event?
Analyze accreditation agency (e.g., OSHA, ACHA, CMS, CDC, CLIA, TJC, AHCA, state agencies) requirements:
Identify which agency(s) would be involved
Define the agency’s purpose
Discuss the agency’s reporting expectations based on the incident

Part 2: Root Cause Analysis: Fishbone Diagram

Create a fishbone diagram
. You will be responsible for creating the CQI Tool (fishbone), completing the tool, copying or taking a screenshot of the completed work, and pasting the completed fishbone diagram into the final document.
If you are unfamiliar with the fishbone, please refer to the Using Quality Improvement Methods for Evaluating Health Care
(Links to an external site.)
article by Siriwardena (2009).
In addition, as a learning resource, the CQI tool listed below is hyperlinked to the Institute for Health Care Improvement website, which discusses and illustrates an example of the Fishbone. Tools: Cause and Effect Diagram
(Links to an external site.)

Part 3: Root Cause Analysis Report

Create a root cause analysis.
Identify the data you would collect to determine the cause.
Give your rationale for choosing the data.
Identify the probable cause, which may include a process failure, human error, cultural biases, policy error, systems error, technology failure, etc., that may have contributed to the sentinel event. Consider the following as applicable to your chosen event as you complete this segment:
What human factors were relevant to the outcome?
What process errors were relevant to the outcome?
Were there any steps in the process that did not occur as intended?
How did the equipment performance affect the outcome?
What are the other areas in the health care organization where this could happen?
Did staff performance during the event meet the expectations?
Develop a corrective action plan that is geared towards eliminating future events.
Explain the steps of implementing the corrective action plan. Consider the following in developing your response to this component:
Identify risk reduction strategies
Improvement of processes or systems
Communication barriers—for example, discuss the communication breakdown that might have contributed to the sentinel event, or what barriers may have occurred to cause the breakdown in communication (e.g., residual intimidation, reluctance to report a coworker, missing information at time of transition of care, etc.).
Training (e.g., orientation, professional development, cultural competency, skills training, in-service)
Equipment (e.g., technology, maintenance, and updates)
Policies and procedures (e.g., new or revised)
Describe the monitoring process that will be used to evaluate the success of the corrective action plan.
Analyze the components that may require the reallocation of budgetary resources. Consider the following as applicable to your sentinel event:
Legal action
Public relations (reputation leading to decreased revenue)
Equipment and supplies
Training and education
Patient-centered communication methods (e.g., informed consent, procedural education, patient involvement [identify or mark the location of the surgical site])
Staffing (e.g., reallocating staff, role responsibilities, hiring temporary or permanent staff)

Paper requirements:

The Executive Summary to CEO capstone assignment

Must be a minimum of 10 double-spaced pages in length (not including title and references pages) and formatted according to APA Style
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as outlined in the Writing Center’s APA Formatting for Microsoft Word
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Must include a separate title page with the following:
Title of paper
Student’s name
Course name and number
Instructor’s name
Date submitted
Must utilize academic voice. See the Academic Voice
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resource for additional guidance.
Must include an introduction and conclusion paragraph. Your introduction paragraph needs to end with a clear thesis statement that indicates the purpose of your paper.
For assistance on writing Introductions & Conclusions
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as well as Writing a Thesis Statement
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, refer to the Writing Center resources.
Must use at least eight credible sources and must have been published within the past ten years.
The Scholarly, Peer-Reviewed, and Other Credible Sources
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table offers additional guidance on appropriate source types. If you have questions about whether a specific source is appropriate for this assignment, please contact your instructor. Your instructor has the final say about the appropriateness of a specific source for a particular assignment.
To assist you in completing the research required for this assignment, view this Library Quick ‘n’ Dirty
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tutorial, which introduces the Library and the research process, and provides some library search tips.
Must document any information used from sources in APA Style as outlined in the Writing Center’s APA: Citing Within Your Paper
(Links to an external site.)
Must include a separate references page that is formatted according to APA Style as outlined in the Writing Center. See the APA: Formatting Your References List
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resource in the Writing Center for specifications.

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