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IHP 315 Final Project Guidelines and Rubric Overview The final project for this course is an error analysis and recommendations paper. Students will review a case study that disc usses a medical error leading to an adverse patient outcome in a hospital or other healthcare organization. Students will determine the type of error that occurred and its causal and contributing factors, and then recommend strategies that can be used to lower the incidence of the error. The final product represents an authentic demonstration of competency because it reflects the IHP 315 course objectives. The project is divided into three milestones , which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. These mi lestones will be submitted in Modules Two, Four, and Five. The final product will be submitted in Module Seven. In this assignment, you will demonstrate your mastery of the following course outcomes: Recommend measurable evidence -based patient safety imp rovement strategies through analysis of factors leading to adverse patient outcomes Develop key elements of disclosure and incident reporting systems that address the needs of patients, families, and healthcare systems and are consistent with state and federal reporting requirements Analyze patient safety culture using appropriate assessment tools for recommending methods to effectively improve culture Propose essential communication and teamwork strategies that are measurable and promote safer patient care in healthcare organizations Prompt In your error analysis and recommendations paper you will answer the following question. What caused the medical error that o ccurred, and how would you suggest that the error could be prevented from happening again? To answer this guiding question, you wil l analyze the medical error in the case study you choose from the Final Project Case Studies document. Specifically, the following critical elements must be addressed: I. Root Cause Analysis (RCA): In this section, you will provide an overview of the details in the provided case study that led to adverse patient outcomes. This overview will be in the form of a flowchart, which you will then use to help you analyze the medical error. Specifically, you should include the following: A. Timeline: Using a flowchart, summarize the events, processes, and staff involved in the timeline of events that led to the medical error. B. Factors: Based on your flowchart, use a modified root cause analysis to do the following: i. Identify two contributing factors that led to the medical error ii. Identify one causal factor that led to the medical error II. Patient Safety Strategies: In this section, you will use the factors you identified to recommend a measurable evidence -based patient safety improvement strategy. Specifically, you should include the following: A. Recommendation: Based on the contributing factors or causal factor that you identified, recommend an evidence -based patient safety improvement strategy. What role would patients and families have in your recommendation? B. Measurement: How will the strategy be measured so that medical staff can determine whether the strategy led to improved patient safety? In other words, what will the primary measure be? What types of data should be collected? III. Disclosure: In this section, you will develop key elements of disclosure and incident reporting systems. Specifically, you should cover the following: A. Details: Based on state and federal reporting requirements and the results of the root cause analysis (RCA), identify the details that would be necessary to disclose the error to the patient and family. B. Method and Preparation: How would you suggest disclosing these details to the patient and family? What preparation would be needed for the staff, patient, and family before the disclosure? C. Reporting: What elements of the RCA and corrective action plan (strategies) would need to be shared with accrediting or regulatory agencies? For example, what elements should be reported to the State Department of Health and Human Services? What should be reported to The Joint Commission? IV. Patient Safety Culture: In this section, you will analyze patient safety culture through the use of a survey as an assessment tool. Specifically, you should address the following: A. Analysis: Analyze all of the patient safety culture survey results at the facility where the error occurred. These results are in your Final Project Case Studies document . W hat does this survey tell you about the patient safety culture at the facility? Based on your analysis, what are the areas for improvement? B. Outcome: In what ways might the outcome have been different if the facility had a stronger patient safety culture? Your response should be based on your analysis of the patient safety culture survey. C. Recommendation: Recommend one method that could be used to improve the patient safety culture. Justify your recommendation with your analysis of the survey. V. Communication: In this section, you will propose communication and teamwork strategies, explaining how these strategies promote safer patient care. Specifically, you should address the following: A. Strategy: What strategy or strategies could be used to improve communication and team building? Explain why you selected the strategy or strategies, basing your response on your analysis of the medical error and the patient safety culture. B. Safer Patient Care: How does the strategy (or strategies) promote safer patient care? What evidence do you have to support your response? C. Measurement: How will the communication and teamwork strategy or strategies be measured? In other words, how will we know that communication improved? Milestone One : Root Cause Analysis and Patient Safety Strategies Milestones In Module Two , you will select one of the case studies provided in the Final Project Case Studies document to be the focus of your entire project. You will then complete a root cause analysis and recommend appropriate patient safety strategies. This milestone will be graded with the Milestone One Rubric. Miles tone Two : Disclosure In Module Four , you will consider disclosure and incident reporting systems that would apply to your chosen case study. This milestone will be graded with the Milestone Two Rubric. Milestone Three : Patient Safety Culture and Communica tion In Module Five , you will develop your analysis of the patient safety culture of your chosen case study and then propose communication and t eamwork strategies to promote patient safety initiatives within your organization. This milestone will be graded with the Milestone Three Rubric. Final Submission : Error Analysis and Recommendations Paper In Module Seven , you will submit your final project. It should be a complete, polished artifact containing all of the critical elements of the final product. It should reflect the incorporation of feedback gained throughout the course and be APA formatted and referenced. This submission will be graded with the Final Project Rubric. Deliverables Milestone Deliverable Module Due Grading One Root Cause Analysis and Patient Safety Strategies 2 Graded separately; Milestone One Rubric Two Disclosure 4 Graded separately; Milestone Two Rubric Three Patient Safety Culture and Communication 5 Graded separately; Milestone Three Rubric Final Submission: Error Analysis and Recommendations Paper 7 Graded separately; Final Project Rubric Final Project Rubric Guidelines for Submission: Your error analysis and recommendations paper should be 6 to 8 pages in length (plus a cover page and references) and must be written in APA format. Use double spacing, 12 -point Times New Roman font, and one -inch margins. All references and citations should be cited in APA format. Critical Elements Exemplary (100%) Proficient (85%) Needs Improvement (55%) Not Evident (0%) Value Root Cause Analysis: Timeline Meets “Proficient” criteria and flowchart is exceptionally detailed and contextualized Using a flowchart, summarizes events, processes, and staff involved in timeline of events that led to medical error, with few gaps in detail Summarizes events, processes, and staff involved in timeline of events that led to medical error but without using a flowchart or with gaps in detail Does not summarize events, processes, and staff involved in timeline of events that led to medical error 5.93 Root Cause Analysis: Factors Meets “Proficient” criteria and root cause analysis is exceptionally well organized, detailed, and insightful Based on flowchart, identifies at least two contributing factors and one causal factor that led to the medical error, using a modified root cause analysis Identifies two contributing factors and one causal factor that led to the medical error but not based on flowchart, without using a modified root cause analysis, or with gaps in accuracy or logic Does not identify two contributing factors and one causal factor that led to the medical error 5.93 Patient Safety Strategies: Recommendation Meets “Proficient” criteria and recommended patient safety improvement strategy demonstrates creativity and innovation Recommends an appropriate evidence -based patient safety improvement strategy based on the identified factors and describes role of patients and families in recommendation Recommends a patient safety improvement strategy and describes role of patients and families in recommendation but strategy is not appropriate based on the identified factors or response has gaps in detail Does not recommend a patient safety improvement strategy 5.93 Patient Safety Strategies:Measurement Meets “Proficient” criteria and explanation demonstrates keen insight into measuring for improvement Explains how the strategy will be measured so that medical staff can determine whether the strategy led to improved patient safety Explains how the strategy will be measured so that medical staff can determine whether the strategy led to improved patient safety, but with gaps in clarity or detail Does not explain how the strategy will be measured so that medical staff can determine whether the strategy led to improved patient safety 5.93 Disclosure: Details Meets “Proficient” criteria and response demonstrates an understanding of the sensitivity needed when disclosing to patients and families Identifies necessary details to disclose the error to the patient and family, based on state and federal reporting requirements and the root cause analysis Identifies necessary details to disclose the error to the patient and family, but details are not based on state and federal reporting requirements or the root cause analysis Does not identify necessary details to disclose the error to the patient and family 7.92 Disclosure: Method and Preparation Meets “Proficient” criteria and response demonstrates an understanding of the sensitivity needed when disclosing to patients and families Explains suggested method and preparation needed for disclosing details to staff, patient, and family Explains suggested method and preparation needed for disclosing details to staff, patient, and family, but with gaps in detail Does not explain suggested method and preparation needed for disclosing details to staff, patient, and family 7.92 Disclosure: Reporting Meets “Proficient” criteria and response demonstrates keen insight into reporting requirements Identifies elements of RCA and corrective action plan that would need to be shared with accrediting or regulatory agencies Identifies elements of RCA and corrective action plan that would need to be shared with accrediting or regulatory agencies, but with gaps in detail or accuracy Does not identify elements of RCA and corrective action plan that would need to be shared with accrediting or regulatory agencies 7.92 Patient Safety Culture: Analysis Meets “Proficient” criteria and analysis is exceptionally robust and thoughtful Analyzes the patient safety culture survey at the facility where the error occurred and identifies areas for improvement based on analysis with few gaps in the details Analyzes the patient safety culture survey at the facility where t he error occurred and identifies areas for improvement, but analysis is cursory or inaccurate or areas for improvement are not based on analysis Does not analyze the patient safety culture survey at the facility where the error occurred and does not identify areas for improvement 7.92 Patient Safety Culture: Outcome Meets “Proficient” criteria and response demonstrates nuanced understanding of patient safety culture Identifies ways the outcome might have been different if the facility had a stronger patient safety culture, primarily based on analysis of patient safety culture survey Identifies ways the outcome might have been different if the facility had a stronger patient safety culture, but response is not based on analysis of patient safety culture survey or has gaps in detail or logic Does not identify ways the outcome might have been different if the facility had a stronger patient safety culture 7.92 Patient Safety Culture:
Recommendation Meets “Proficient” criteria and justification is exceptionally well aligned with analysis of patient safety culture survey Recommends method for improving patient safety culture, justifying recommendation with analysis of survey Recommends method for improving patient safety culture, but does not justify recommendation with analysis of survey or response has gaps in detail or logic Does not recommend method for improving patient safety culture 7.92 Communication: Strategy Meets “Proficient” criteria and response demonstrates keen insight into strategies for communication and team building Proposes strategy or strategies that could be used to improve communication and team building, basing explanation on analysis of medical error and patient safety culture Proposes strategy or strategies that could be used to improve communication and team building, but explanation is not based on analysis or has gaps in detail or logic Does not propose strategy or strategies that could be used to improve communication and team building 7.92 Communication: Safer Patient Care Meets “Proficient” criteria and response demonstrates keen insight into connection between communication and improving patient care Explains how strategy promotes safer patient care, supporting response with evidence Explains how strategy promotes safer patient care, but with significant gaps in detail, logic, or support Does not explain how strategy promotes safer patient care 7.92 Communication:
Measurement Meets “Proficient” criteria and response demonstrates a nua nced understanding of the importance of measuring improved communication Explains how the communication and teamwork strategy or strategies will be measured with minimal missing, unclear, or illogical details Explains how the communication and teamwork strategy or strategies will be measured, but with gaps in clarity, detail, or logic Does not explain how the communication and teamwork strategy or strategies will be measured 7.92 Articulation of Response Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy -to-read format Submission has no major errors related to citations, grammar, spelling, syntax, or organization Submission has major errors related to citatio ns, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas 5 Total 100%
