Assessment 5 ContextChange Leadership: Risk Management and Patient Safety
Transforming from reactive to proactive mode requires health care executives to understand
the competencies central to high-reliability organizational leadership. Youngberg (2011)
outlines the relevant leadership competencies as:
• The ability to reinforce the systems and structure to promote safety based on evidence
drawn from the science of safety.
• The ability to create a culture that develops and supports those who provide care and
services to allow for greater capacity for teamwork, risk awareness, risk mitigation, and
resiliency.
• The ability to focus and align resources to create and promote advancements in safety.
• The commitment to assure that evidence-based, patient-centered, and system-centered
work is done.
• The promise to all concerned that honest, ethical dialogue with patients is necessary
when breaches in safety occur. (p. 296)
Additionally, health care executives must understand the characteristics of high-reliability
organizations and the associated risk management responsibilities. These characteristics
include trust and transparency, reporting, flexibility in hierarchy, justice and
accountability, engagement, and dedication to organizational learning (Youngberg, 2011).
Themes for Success in Leadership
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Shared sense of purpose.
Authenticity.
A hands-on approach.
Data-driven, accountable, high standards.
Focus on results.
Clarity of expectations.
A collaborative culture.
Respect.
Limited hierarchy.
Open communication.
Teamwork (Youngberg, 2011).
The National Patient Safety Goals and Strategic Direction
The National Patient Safety Goals and Strategic Direction outlined by the National Quality
Forum (n.d.), CMS requirements (HHS, n.d.), and the Joint Commission (2017) standards
make it clear that effective leaders must be transformational.
The National Center for Healthcare Leadership (NCHL) Competencies for Healthcare
Executives includes three domains:
• Quality. Risk Management, and Regulatory Compliance.
It is appropriate to reflect upon how quality, risk, and regulatory compliance are affected,
given the strategic direction from CMS and the NCHL competencies requisite for
transformational leadership (HHS, n.d.; NCHL, n.d.).
MHA-FP5014 Assessment 5 Context
1
Assessment 5 Context
Personal Reflection
You may wish to reflect upon your own leadership development plans, and assess highimpact competencies for implementation of the content and context of this course. It may be
interesting to compare your ratings from before you began this course to your assessment of
NCHL competencies, now that you have entered the final phase of the course.
If you were to construct a balanced scorecard for your organization, which areas would your
position effect? Take a step outside the mechanics of data analysis, strategic direction, and
industry and consider your role as a future health care leader.
Ethical Leadership
Implicit within the NHCL competencies is the value of ethical leadership. The American
College for Healthcare Executives’ code of ethics serves as a reminder that our actions should
be patient- and community-focused (ACHE, n.d.). As a health care leader, you will be
expected to own the vision and mission, support the strategic direction, and remain flexible
while upholding your role as fiduciaries.
Professional Communication
Another aspect of leading within this dynamic industry is the need to practice professional
communications. What are the most appropriate forms of communication to support your
efforts? E-mail and social media communications are fraught with potential miscommunication
and liability issues. It is important to explore issues associated with a professional
communication.
References
American College of Healthcare Executives. (n.d.). ACHE code of ethics. Retrieved from
http://www.ache.org/ABT_ACHE/code.cfm
National Center for Healthcare Leadership. (n.d.). NCHL Health Leadership
Competency Model. Retrieved from http://www.nchl.org/static.asp?path=2852,3238
National Quality Forum. (n.d.). NQF’s mission and vision. Retrieved from
http://www.qualityforum.org/About_NQF/Mission_and_Vision.aspx
The Joint Commission. (2017). Facts about the national patient safety goals. Retrieved from
http://www.jointcommission.org/facts_about_the_national_patient_safety_goals
U.S. Department of Health & Human Services. (n.d.). Accountable care organizations.
Retrieved from http://oig.hhs.gov/compliance/accountable-care-organizations/index.asp
Youngberg, B. J. (2011). Principles of risk management and patient safety. Sudbury, MA: Jones and
Bartlett.
MHA-FP5014 Assessment 5 Context
2
Running head: PROCESS IMPROVEMENT PROPOSAL
Process Improvement Proposal
Your Name
Capella University
MHA FlexPath 5014
Assessment 5
1
PROCESS IMPROVEMENT PROPOSAL
2
Abstract
[Review the APA rules/requirements for an Abstract]
PROCESS IMPROVEMENT PROPOSAL
Table of Content
3
PROCESS IMPROVEMENT PROPOSAL
4
Introduction
[Provide a brief introduction (main themes of your paper) here and delete all
statements within brackets, such as this paragraph, and replace with your
discussion. Also, before you begin, review the “Scoring Guide” and understand the
difference between “Distinguished”, “Proficient”, “Basic” and “Non-Performance”. These
“Scoring Guides” are used to grade the assignment. This is why each Template is set
up with headings (below) that correspond with the “Scoring Guides” for this specific
assignment. Please leave the Headings (below) in the paper.]
Existing Organizational Structure, Mission, Vision Analysis
[Analyze existing organizational structure, mission and vision]
Finances, Internal Process, Learning & Growth, Customer Satisfaction
[Provide a macro-level discussion of finances, internal processes, learning and
growth and customer satisfaction.]
Evidence-Based and Best-Practice for Monitoring & Improving
[Recommend evidence-based and best practices for monitoring and improving
discussion.]
Organization’s Values
[Convey the organization’s values through an ethical, organizational, and
directional strategy to impact the needed changes for quality improvement.]
Conclusion
[Provide a conclusion.]
PROCESS IMPROVEMENT PROPOSAL
5
References
[A minimum six (6) resources]
Overview
Generate recommendations for process improvement and organizational fitness for a
selected organization in the form of a 6– 8-page proposal that is targeted for its
management team.
Note: The assessments in this course build upon each other, so you are strongly
encouraged to complete them in a sequence.
Health care leaders function within a complex, high-risk environment where errors can
lead to injury and death. The goal of any health care leader is to assess and manage risk,
while concurrently promoting a culture of patient safety.
By successfully completing this assessment, you will demonstrate your proficiency in the
following course competencies and assessment criteria:
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Competency 1: Conduct an environmental assessment to identify quality- and riskmanagement priorities for a health care organization.
• Analyze existing organizational structures, mission, and vision.
Competency 3: Analyze the process and outcomes of a care quality- or risk-management
issue.
• Provide macro-level discussion on finances, internal processes, learning and
growth, and also customer satisfaction.
Competency 4: Analyze applicable legal and ethical institution-based values as they
relate to quality assessment.
• Convey the organization’s values through an ethical, organizational, and
directional strategy to impact the needed changes for quality improvement.
• Recommend evidence-based and best practices for monitoring and improving
discussion.
Competency 5: Communicate in a manner that is scholarly, professional, and consistent
with expectations for professionals in health care administration.
• Communicate information and ideas accurately, including reference citations and
correct grammar.
Content
Patient safety is the cornerstone of high-quality care.
SHOW LESS
Youngberg (2011) addresses the need for leaders to create a systemic mindfulness of
patient safety within the high-risk health care delivery environment. Further, the author
discusses high-reliability organizations, which attain next to zero error rates, despite a
great propensity for error or catastrophic events.
Read further in the Assessment 5 Context [PDF] document, which contains important
information on the following topics related to change leadership, risk management, and
patient safety:
• Themes for Success in Leadership.
• The National Patient Safety Goals and Strategic Direction.
• Personal Reflection.
• Ethical Leadership.
• Professional Communication.
Questions to Consider
As you prepare to complete this assessment, you may want to think about other related
issues to deepen your understanding or broaden your viewpoint. You are encouraged to
consider the questions below and discuss them with a fellow learner, a work associate,
an interested friend, or a member of your professional community. Note that these
questions are for your own development and exploration and do not need to be
completed or submitted as a part of your assessment.
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How does a health care leader establish a culture of patient safety?
• How are risks to patient safety assessed and managed in your current or
future work setting?
• What are the other types of risks that are assessed and managed?
• What are the important factors that need to be monitored in your selected
work setting?
• How can you contribute to risk management and patient safety within your
job?
Imagine that you are the new CEO of your organization, and are charged with
transforming the previous status quo to an efficient, high-performing accountable care
organization.
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Which tools would you put to work in your new position?
What types of individuals would be needed for your executive leadership
team?
What competencies might be important to the team members?
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What processes, structural models, or frameworks from this course might
help you as a transformational leader?
Resources
Required Resources
Balanced Scorecard
The following resources are required to complete this assessment.
This article introduces the concept of a balanced scored to motivate and measure a
business unit performance.
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Kaplan, R. S., & Norton, D. P. (1996). Linking the balanced scorecard to
strategy. California Management Review, 39(1), 53–79.
The following reading is available full-text in the Capella University Library. Search for
each article by clicking the linked title and following the instructions in the Library
Guide. This article explores measure that drives performance using a balanced
scorecard.
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Kaplan, R. S., & Norton, D. P. (1992). The balanced scorecard: Measures that drive
performance. Harvard Business Review, 70(1), 71–79.
Assignment Instruction
Note: You should complete this assessment last.
Preparation
The goal of this assessment is to generate recommendations, in the form of a proposal
for process improvement and organizational fitness. Make your recommendations for
the organization you selected in Assessment 4 for the balanced scorecard presentation.
Apply the concepts of balanced scorecards to create your recommendations.
Instructions
In your proposal, use specific language and include evidence-based concepts from peerreviewed literature, including a minimum of four outside peer-reviewed sources.
Communicate information and ideas clearly, accurately, and concisely, including
reference citations and using correct grammar. Include the following in your proposal:
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Describe the selected organization, including its vision and mission.
Analyze the company using any adaptation of the Kaplan and Norton balanced
scorecard framework that fits your selected organization. Refer to the materials in the
Resources.
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Communicate vision, strategy, objectives, measures, targets, and initiatives for each of
the following four elements through a macro-level discussion:
• Financial performance measures.
• Internal business processes.
• Learning and growth.
• Customer satisfaction.
Convey the organization’s values through an ethical, organizational, and directional
strategy.
Recommend evidence-based and best practices for monitoring and improving
discussions.
Generate one recommendation for each of the following:
• Process improvements.
• Quality improvements.
• Organizational efficiency.
• Learning implementation.
• Implementation and evaluation.
Additional Requirements
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Written communication: Written communication should be free from errors that detract
from the overall message.
APA formatting: Resources and citations should be formatted according to APA style and
formatting guidelines. Use APA format for all of the following:
• Cover page.
• Abstract.
• Table of contents, including a list of figures and tables.
• Headings and subheadings.
• Reference list.
Number of resources: A minimum of 6 resources. The following Norton and Kaplan
articles will serve as two resources.
• The Balanced Scorecard: Measures that Drive Performance.
• Linking the Balanced Scorecard to Strategy.
Length of paper: 6–8 typed double-spaced pages.
Font and font size: Arial, 10-point.
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Formatting
Title Page
Citation
Outline
