Albany College of Pharmacy Healthcare Management Case Study Analysis

Albany College of Pharmacy Healthcare Management Case Study Analysis

1. Case Analysis (Individual) –Quality/Patient Safety Improvement Plan: Students will analyze utilizing QI tools. The case is (it is hard to kill 15yr) students will use the information, and data provided from the case they identified asnd utilize specific QI/PS tools and techniques to address the problem at hand. Deliverables will include a QI/Patient Safety Case Analysis that addresses – what happened (incident), why it happened (contributory factors), key contributory factors (two to three), recommendations to address the key contributory factors (with evidence to support effectiveness of interventions), measures to assess improvement and rationale. You will provide charts, graphs and use the learning from defects tool and other tools – fish bone, pareto chart etc.Length of the paper: The case analysis should be six to (double-spaced) excluding appendices, cover page, and references.You must use sub-headings e.g. what happened, why/contributory factors, key contributory factors that led to the event, recommendations to address key contributory factors and rationale, measures to assess improvement and conclusion.Please refer to detailed instructions on the course attached

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ISM FREE PAPER NOWNote – A thorough case analysis requires you to read the case at least twice, make notes, use facts and provide recommendations that will address the issues identified.Please familiarize yourself with the tools (learning from defect and seven basic quality tools).All the material will be attached to help you with this case.

* the case, the instructions and QI tool. The book is (Introduction to Healthcare Quality Management, Third Edition Patrice L. Spath ) I do not have*

HCMN 435– Patient Safety Case Analysis Paper – Instructions

Instructions: First read the case you have chosen from the case repository on blackboard thoroughly AND review the “Learning from Defects” tool provided. This tool was developed and adapted by the Quality and Safety Research Group led by Professor Pronovost et al to help health care providers identify and learn from defects utilizing a systems approach.  The contributory factors framework helps providers gain a deeper appreciation of harm as it occurs usually due to breakdown of systems (multiple factors).  It steers clear of blame and punitive behavior and encourages teams to focus on learning.

Attempt ALL four questions in response to the case provided below as though you are part of the team investigating.  What happened, why (contributory factors), key contributory factors that led to the event. Be sure to categorize your contributory factors into patient factors, caregiver factors, task, teamwork and communication etc.   Please use QI tools such as flow chart, cause and effect/fishbone and pareto charts to justify your interventions.  These charts should be part of your appendices.  Suggest interventions so that such events will not occur in the future (be sure that the interventions you suggest address the key contributory factors).  Then provide measures that you will assess to know if your suggested interventions are working.  Assume that you have implemented your recommendations. How will you know that these worked to reduce/eliminate risk? What measures would help confirm improvements.  Please include an abstract as your first page and include titles and sub-titles (e.g. what happened, why (contributory factors), key contributory factors etc.

Try to be objective and use facts from the case. It is recommended that you take time reading the case and ascertain key contributory factors prior to suggesting any intervention.  You may use additional sheets of paper to make rough notes, provide your rationale for choices/additional descriptions, flow chart etc.  You should prepare an outline first for your case analysis.  Feel free to visit your instructor during office hours for any questions that you may have concerning this assignment.

Format and page length:  APA 6.0 format, and 6 pages excluding appendices and cover page– see syllabus for other details.

Grading Rubric:  Your responses will be graded on the basis of clarity of thought, originality, accuracy and specificity of content, and the approach utilized in analyzing the defect and providing recommendations.

Possible maximum points by question:

Question # 1 (10 points),

Question # 2 (40 points),

Question # 3 (40 points),

Question # 4 (10 points).

Total = 100 points