The purpose of this assignment is to analyze how an organization’s quality and improvement processes contribute to its risk management program.
This assignment builds on the Risk Management Program Analysis – Part One assignment you completed in Topic 1 of this course.
Assume that the sample risk management program you analyzed in Topic 1 was implemented and is now currently in use by your health care employer/organization. Further assume that your supervisor has asked you to create a high?level summary brief of this new risk management program to share with a group of administrative personnel from a newly created community health organization in your state who has enlisted your organization’s assistance in developing their own risk management policies and procedures.
Compose a 1,250?1,500 word summary brief that expands upon the elements you first addressed in the Topic 1 assignment. In this summary brief, address the following points regarding your health care organization and its risk management program:
Explain the role of your organization’s MIPPA-approved accreditation body (e.g., JC, ACR, IAC) in the evaluation of your institution’s quality improvement and risk management processes.
Describe the roles that different levels of administrative personnel play in healthcare ethics and establishing or sustaining employer/employee-focused organizational risk management strategies and operational policies.

Illustrate how your organization’s risk management and compliance programs support ethical standards, patient consent, and patient rights and responsibilities.
Explain the legal and ethical responsibilities health care professionals face in upholding risk management policies and administering safe health care at your organization.
Relate how your organization’s quality improvement processes support and contribute to its overall journey to excellence.
In addition to your textbook, you are required to support your analysis with a minimum of three peer?reviewed references.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

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Topic: Infection   control in healthcare organization.
In collaboration with the approved course preceptor, students will identify a specific evidence-based topic for the capstone project change proposal. Students should consider the clinical environment in which they are currently employed or have recently worked. The capstone project topic can be a clinical practice problem, an organizational issue, a leadership or quality improvement initiative, or an unmet educational need specific to a patient population or community. The student may also choose to work with an interprofessional collaborative team.
Students should select a topic that aligns to their area of interest as well as the clinical practice setting in which practice hours are completed.
Capstone project topic
The problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project that will be the focus of the change proposal.
The setting or context in which the problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project can be observed.
A description (providing a high level of detail) regarding the problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project.
Effect of the problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project.
Significance of the topic and its implications for nursing practice.
A proposed solution to the identified project topic with an explanation of how it will affect nursing practice.
You are required to cite to a minimum of eight peer-reviewed sources to complete this assignment. Sources must be published within the last 5 years, appropriate for the assignment criteria, and relevant to nursing practice. Plan your time accordingly to complete this assignment.

City Hospital is a public, 500-bed hospital located in a major northern U.S. city. The hospital caters to many indigent clients, but it is known for its strong medical residency program and research conducted in conjunction with the medical school.
Characters
Maria Rawls, employee
Juan Gonzalez, immediate supervisor
Connie Grant, manager
Gary Tibbitts, human resource manager
Situation Background
Maria Rawls has been working in the accounting department of City Hospital for 18 months. Before that, she worked as an accountant in her uncle’s small accounting firm.
While at City Hospital, Maria’s performance evaluations have been low to average. So far, she has received three periodic performance evaluations and a 2 percent raise that was given to all employees. Maria, however, did not receive a merit raise that was awarded to some of the higher-performing employees in her department.
Maria has not been able to keep up with the procedures involved with the new accounting software the hospital recently purchased. She has fallen behind with her work despite working late. Maria must frequently consult the operating manual for the accounting software, although none of her co-workers seem to be having the same problems learning the new software.
Maria’s previous supervisor at City Hospital seemed more willing to work with Maria and overlook some of her performance deficiencies. Maria’s new supervisor, Juan Gonzalez, appears to have more stringent standards and has come to the HR department requesting assistance with respect to resolving Maria’s performance issues.
Maria’s Background
Accounting has never been her passion, but Maria wanted a stable profession. While working on her degree, she was employed part-time as an accountant in her uncle’s small accounting firm.
Maria has been working at City Hospital for 18 months. This is her first job after completing her Master of Accountancy degree at State University. She is taking the Certified Public Accountant (CPA) examination in stages and has already completed two sections. Thus far, she has passed one section and failed one section.
Maria got along really well with her previous boss at City Hospital. She gave Maria work she knew that Maria could handle, even though the official job description could have required Maria to perform additional (and unfamiliar) tasks.
However, Maria’s new boss, Juan, is not as easy going. Maria doesn’t like Juan, and Maria
thinks that he is out to get her. Also, Maria’s having a hard time learning the new accounting software that was recently installed by the hospital.
Earlier this week, Maria had a meeting with Juan to go over her recent performance appraisal. During this meeting, Juan highlighted that she was late with 5 percent of her weekly reports and that she had an error rate that was 2.5 percent higher than the rest of the department. He also noted that she has not fully learned the new accounting software. Moreover, he commented that it seems as though Maria is taking a long time to obtain your CPA designation.
A few days later, Juan told Maria that he wants to meet with her, his immediate supervisor (Connie Grant, the manager of the accounting department) and the HR manager (Gary Tibbitts) to discuss putting her on a PIP. Needless to say, Maria is quite upset about being put on a PIP, but realizes she has no choice but to go along with it until she can find another job.
Questions
What seem to be the key performance criteria that Juan is using? Are they appropriate? Are these objective or subjective?
Is Juan doing anything illegal? Explain why you think he is or is not.
Determine what the PIP plan needs to contain. Then determine what resources, if any, that the organization needs to expend to help Maria.
The case makes it seem that Maria feels powerless and that she has no options but to quit or comply. Is this true, or does she have any options?
If you were the HR manager, what else could you do to resolve the situation? Come up with at least two different alternatives that could be used if Maria’s performance is not better after the PIP. These alternatives should not involve firing Maria.

Science Meets Real Life
Each and every day, you are faced with having to make split-second decisions, and the need to solve random problems that you encounter. As you have learned in Unit 1 and currently in Unit 2, in order to reach those decisions and work those problems out, you are subconsciously using the scientific method. In this Assignment, you will create a PowerPoint presentation to explain how you would use the scientific method to solve the following scenario.
Scenario: You have agreed to take care of your friend’s dog; Buddy, while she goes on a trip to Antarctica. On your two-hour trip to take your friend to the airport you get so caught up talking about her upcoming adventure that you do not have any time to ask questions about her new dog (Buddy) who is riding in the backseat. After you drop your friend off, just in time to catch her flight, you drive the two hours back home and realize that your friend accidently took the dog’s bag with when she ran into the airport. You realize that you do not have access to your friend’s house and cannot contact her. It is a new dog so there is no one else you can contact that knows its normal routine. You stop at the local pet store and ask the salesperson to help you pick out food and supplies to take care of Buddy for the next few weeks. They send you home with a bag of salmon and potato dry dog food, a few toys, and a dog bed. When you get home, you put some of the dog food in a plastic bowl that you had been using to store oranges and lemons. You offer this to Buddy, but he refuses to eat his dinner. This puts you in a little bit of a panic since your friend is on a long flight and will then be on a ship to Antarctica so contacting her will be difficult. You take a deep breath and decide that you can try to solve this problem on your own.
Prepare a PowerPoint presentation to show how you would apply each step of the scientific method to try to solve this problem using the proper terminology (hypothesis, experiment, etc.). Use a minimum of three references to provide factual support.
A template is provided to get you started. Additional slides should be added to address all the questions in this assignment and cite your sources. You are welcome to modify this template to suit your needs, being sure to meet the assignment requirements. Make sure your PowerPoint® presentation addresses the following questions.

What are the steps of the scientific method? List them out and provide a short description in your own words of what happens during each step.
To collect your data, read through the scenario carefully and on a slide provide a list of everything that you know about the situation with Buddy.
Create a testable hypothesis for why Buddy is not eating that is consistent with the data in the scenario:e., Buddy is not eating because I did not buy the type of dog food that he is used to. Indicate which pieces of evidence you used to develop your hypothesis.
Outline how you would set up an experiment to test the following hypothesis: Buddy is not eating because I did not buy the type of dog food that he is used to. 
Do some research on independent and dependent variables. Identify the independent and dependent variables in your experiment.
List three things that you should keep constant (the same) during your experiment so that they don’t influence the outcome of your experiment.
Identify what you would do if:

The results of your experiment supported your hypothesis.
The results of your experiment did not support your hypothesis.

Explain what you would do in the following two situations:

You know you can contact your friend at some point soon but only for a short time. What three testable questions would you want to ask her to help support or disprove the proposed hypothesis?
Your neighbor comes over to help out with Buddy and poses the following hypothesis: Buddy won’t eat because he feels that his owner is unlucky when she travels and may get hurt. Is this a testable hypothesis? If so, please explain how you would test it. If not, please explain why it is not testable in the context of the scientific method. 

Create a 3-5-page submission in which you develop a PICO(T) question for a specific care issue and evaluate the evidence you locate, which could help to answer the question.Introduction
PICO(T) is an acronym that helps researchers and practitioners define aspects of a potential study or investigation. It stands for:

P – Patient/population/problem.
I – Intervention.
C – Comparison (of potential interventions, typically).
O – Outcome(s).
T – Time frame (if time frame is relevant).
The end goal of applying PICO(T) is to develop a question that can help guide the search for evidence (Boswell & Cannon, 2015). From this perspective, a PICO(T) question can be a valuable starting point for nurses who are starting to apply an evidence-based model or EBPs. By taking the time to precisely define the areas in which the nurse will be looking for evidence, searches become more efficient and effective. Essentially, by precisely defining the types of evidence within specific areas, the nurse will be more likely to discover relevant and useful evidence during their search.You are encouraged to complete the Vila Health PCI(T) Process activity before you develop the plan proposal. This activity offers an opportunity to practice working through creating a PICO(T) question within the context of an issue at a Vila Health facility. These skills will be necessary to complete Assessment 3 successfully. This is for your own practice and self-assessment and demonstrates your engagement in the course.Reference
Boswell, C., & Cannon, S. (2015). Introduction to nursing research. Jones & Bartlett Learning.Professional Context
As a baccalaureate-prepared nurse, you will be responsible for locating and identifying credible and scholarly resources to incorporate the best available evidence for the purposes of enhancing clinical reasoning and judgement skills. When reliable and relevant evidence-based findings are utilized, patients, health care systems, and nursing practice outcomes are positively impacted.PICO(T) is a framework that can help you structure your definition of the issue, potential approach that you are going to use, and your predictions related to the issue. Word choice is important in the PICO(T) process because different word choices for similar concepts will lead you toward different existing evidence and research studies that would help inform the development of your initial question.Scenario
For this assessment, please use an issue of interest from your current or past nursing practice.If you do not have an issue of interest from your personal nursing practice, then review the optional Case Studies presented in the resources and select one of those as the basis for your assessment.Instructions
For this assessment, select an issue of interest an apply the PICO(T) process to define the question and research it.Your initial goal is to define the population, intervention, comparison, and outcome. In some cases, a time frame is relevant and you should include that as well, when writing a question you can research related to your issue of interest. After you define your question, research it, and organize your initial findings, select the two sources of evidence that seem the most relevant to your question and analyze them in more depth. Specifically, interpret each source’s specific findings and best practices related to your issues, as well explain how the evidence would help you plan and make decisions related to your question.If you need some structure to organize your initial thoughts and research, the PICOT Question and Research Template document (accessible from the “Create PICO(T) Questions” page in the Capella library’s Evidence Based Practice guide) might be helpful.In your submission, make sure you address the following grading criteria:
Define a practice issue to be explored via a PICO(T) approach.
Identify sources of evidence that could be potentially effective in answering a PICO(T) question.
Explain the findings from articles or other sources of evidence.
Explain the relevance of the findings from chosen sources of evidence to making decision related to a PICO(T) question.

Scenario
Chaparral Regional Hospital is a small, urban hospital of approximately 60 beds, and offers the following:

Emergency room services
Intensive care
Surgical care
Obstetrics
Diagnostic services
Some rehabilitation therapies
Inpatient pharmacy services
Geriatric services and
Consumer physician referral services

Recently, the CEO has been hearing complaints from both patients and staff. You have been hired to design and implement a Quality Improvement Plan to help uncover quality problems and satisfactorily resolve them.
Scenario Continued
Your CEO has requested that you provide employee training on Quality Improvement. You have done an initial survey of patient satisfaction, and the CEO has asked you to explain how the data will be analyzed, using this initial data.
Given the variety of complaints coming from both employees and patients, it is critical for everyone to understand the importance of conducting the survey and obtaining solid data.
The list below shows the number of responses based on questions with ratings for Great, Good, OK, Fair, Poor, and No Response out of a total of 40.
Facility and Convenience

Hours of Operations – 10, 17, 3, 0, 10, and 0
Convenience of location – 10, 15, 5, 3, 3, and 4
Cleanliness – 11, 14, 8, 4, 3, and 0
Waiting time in reception area – 9, 16, 0, 4, 11, and 0
Comfort while waiting – 20, 10, 5, 5, 0, and 0

Staff

Explained procedure – 17, 9, 8, 0, 6, and 0
Questions answered – 11, 15, 7, 2, 3, and 2
Friendly and helpful – 21, 5, 5, 7, 2, and 0
Knowledgeable and professional – 6, 21, 4, 3, 3, 3, and 0
Modesty respected – 12, 14, 8, 0, 6, and 0
Confidentiality respected (HIPAA) – 10, 10, 14, 5, 1, and0

Overall Satisfaction

Overall impression of visit – 30, 0, 5, 3, 2, and 0
Willingness to return – 31, 0, 9, 0, 0, and 0
Likelihood of referring to others – 32, 0, 4, 3, 1, and 0

Respondents were also asked about their wait times. Here is the data on wait times:
Number responding (Wait time before being checked in at Reception)

4 – 10 minutes
16 – 15 minutes
8 – 20 minutes
12 – 25 minutes

Number responding (Wait time before being seen by a healthcare professional)

2 – 10 minutes
6 – 15 minutes
10 – 20 minutes
22 – 25 minutes

Instructions
You are to create an agenda for the training and a memo with bullet points to present the statistical analysis of the initial data. The memo should include an explanation of each of the statistical results. In particular, you should be able to explain what the results mean to the facility.
Determine the percentages of the following:

Percent who responded with a 5 (Great) on “Overall impression of the visit”
Percent who responded with a 2 (Fair) or 1 (Poor) on “Overall impression of the visit”
Percent who responded with a 5 (Great) on “Willingness to return”
Percent who responded with less than 5 on “Willingness to return”
In the area of “Facility and Convenience,” which indicator had the highest percentage of 5 (Great) responses? Which had the lowest?
In the area of “Staff,” which indicator had the highest percentage of 5 (Great) responses? Which had the lowest?

What is the mean waiting time in the reception area?
What is the mean waiting time to see a healthcare professional?
Microsoft Word has many memo templates. In your memo, be sure to address each statistical analysis and what it means to the facility. Why ask these questions? How could the data be used for quality improvement?
An agenda can set the tone for a meeting. It is an important tool to ensure meetings are staying on track and meeting all of the objectives. Create a detailed meeting agenda for a meeting you will hold with your supervisor and fellow department heads discussing your findings (Hint: Microsoft Word has many agenda templates).
Make sure to include the following in the agenda:

Explain each statistical example
How that data would be used
The majority of the agenda should be focused on data analysis and its use in QI plans

Make sure to include the following in the agenda:

Explain each statistical example
How that data would be used
The majority of the agenda should be focused on data analysis and its use in QI plans