MEDS20001 2017 Assessment 2
Word count 2000
"You need to be aware that this is a non-graded unit, all assessment items are Pass/fail in nature. As per the Assessment Procedures document, for such units all items must be completed by the due date and there is no provision for a late penalty. In the absence of an approved extension, any assessment not completed by the due date will receive a fail score. Any student who fails a pass/fail assessment item or any assessment item in a non-graded unit will be deemed to have failed that unit."
QUALITY IMPROVEMENT PORTFOLIO
Quality practice in healthcare is about enhancing patient care with the aim of reducing morbidity and mortality. When an adverse event in health care occurs it can have devastating and far reaching effects. It may have an impact on those directly involved - patients, relatives, staff and visitors - and on the reputation of the healthcare organisation, the service or the profession within which the incident occurred. The steps to implementing quality change in patient care are many and are encompassed in various quality improvement frameworks.
You are going to take part in a quality improvement and risk management process related to experiences in a medical imaging department, as part of a "clinical audit."
You will complete the quality improvement tools, and make relevant evidence based comments, to produce a portfolio style report in response to the task posed.
Portfolio Requirements – Tasks
The portfolio will be divided into subsections - one for each tasks. Your portfolio will include a range of quality improvement tools for you to complete and submit.
1:The first part of this assessment task will be spent describing problems in a sonographic environment and identifying contributing factors.
a) List 5 (five) adverse events, or potential adverse events, from within a clinical sonographic department and describe 2 (two) in depth.
b) Fish Bone Diagram
Complete a fish bone diagram for one (1) adverse event, or potential adverse event, in the clinical workplace, as described in 1a.
2: In the second part of the assessment you will analyze one problem with the aim of developing a solution and implementation plan. Use the FADE method (as detailed below) to undertake this section.
a) Focus on the problem and construct a Priority Ranking Tool. Complete a priority ranking tool to include each of Five (5) adverse events discussed in part 1. This is to be accompanied by a brief rationale for the allocation of the 'highest total problem priority' in the table. You will support your decision with evidence (references). For the 'highest total problem priority' identify three (3) possible ideas for improvement which you would advocate for implementation.
b) Analyse to decide what you need to know. Gather baseline data related to this problem by talking to two clinical colleagues about their experiences.List and discuss the most influential factors identified and include a limited identification of root causes / barrier analysis.
c) Develop a solution and implementation plan. List possible solutions, select one for further development giving rationale for its selection and outline an implementation plan for this solution. Discuss approaches for implementing change, engagement with key personnel and the probability of success.
You will not execute the "e" in the FADE method or monitor implementation plan.
3: Quality Management Tables
Complete five (5) quality management tables about one (1) of the adverse events you identified in part 1.
a) Management causation scale, to determine whether medical management rather than disease process caused an adverse event.
b) Medical management analysis severity scale, to rate the severity and preventability of an adverse events.
c) An error causation scale
d) Assessment of the preventability of adverse errors
e) What further action would you recommend? Include discussion of opportunities to implement proactive risk managment methods, such as barriers, trigger tools, benchmarking, indicators, national databases and methods to facilitate patients taking an active role in prevention.
4: Risk Assessment Tables
Complete a task / activity risk assessment matrix / register to include ten (10) possible hazards in the clinical workplace.
Complete a partial risk assessment based on a week in your clinical environment.
This will involve describing ten possible hazards and the risk(s) associated with each hazard, an evaluation of each risk using a risk matrix / register and a description/ evaluation of precautions likely to reduce consequences and/or likelihood.
a) Step 1: Identify and describe ten possible hazards ( activities that could go wrong ) in your clinical days work-related activities. Describe the activity within the context of the physical and emotional environment,and the culture of the organisation and the staff who perform the activity, include any up-to-date research findings or worldwide database records of clinical incidents or media reports related to this hazard, include things which you know, have observed or heard have either gone wrong in the past or near-miss incidents.
b) Step 2: Decide who might be harmed and how ( what can go wrong? Who is exposed to the hazard?)
People will make mistakes so it is neccessary to anticipate some degree of human error and try to prevent the error resulting in harm.
Describe each risk associated with that hazard separately and clearly.
c) Step 3: Evaluate the risks: Consider both consequences (how bad?) and likelihood ( how often?). Is there need for additional action?
The law requires everyone providing a service to do everything reasonably practicable to protect patients from harm.Complete a risk matrix / register. Once a risk has been identified the matrix is used to estimate the chances of an incident occuring or recurring,taking into account the measure in place to prevent it. The chances are rated from unlikely to very likely. The matrix is used to assess the actual or potential consequences of the risk to patients.
Describe precautions (controls) that will most likely reduce consequences and/or likelihood. Re-evaluate the risks assuming that the precautions ( controls) have been taken.
5. You will measure and evaluate the patient safety culture in your workplace.
Complete the Manchester Patient Safety Framework Evaluation Sheets, in partnership with a work colleague, to measure the patient safety culture in your clinical workplace.
The "safety culture" is a new concept in the health sector and can be difficult to assess and change. You are going to use the Manchester Patient Safety Framework (MaPSaF) - Ambulance, to measure the patient safety culture in your clinical workplace. This framework has been adapted for use in various health care professions, but as yet, not medical imaging.
How to use the Manchester Patient Safety Framework (MaPSaF):
a. For each of the nine aspects of safety culture on the final page (7) of the Manchester Patient Safety Framework each person selects the description that best fits the organisation and /or team being assessed. Do this individually and privately, with no discussion. Use a T (team) or O (organisation) on the evaluation sheet to indicate your choices. If you really can’t decide between two of the descriptions, tick both. This will give you an indication of the current patient safety culture profile in your organisation and / or team.
b. Now discuss your profiles with your colleague. You may notice differences, if this happens discuss possible reasons. Address each dimension in turn and see if you can reach consensus.
c. Consider the overall patient safety culture picture for your organisation and /or team. The emerging picture may not be uniform- there will be areas where your organisation and / or team is doing well and in other areas less well.
d. Produce a written description of this patient safety culture picture for your organisation and /or team. Where things are going less well consider the descriptions of more mature risk management cultures. Why is your organisation not like that? How can you move to a higher level? Include responses to these questions in your description. Reference your discussion using up-to-date literature.
Submit the completed Manchester Patient Safety Framework Evaluation Sheets and produce a brief written discussion of your results.
You will support your analysis with evidence (references).
6. Diagnostic report
A sonographers report communicates an interpretation of sonographic findings and patient history.
The process of translation into a final report for the referrer is a potential source of error. You will consider strategies which could minimise this error.
You will produce a final report for the referrer based on a given sonographers worksheet, and other relevant data.
You will discuss potential errors and miimisation strategies.
These quality improvement tools will form the body of the portfolio. Your portfolio will consist of a series of chapters corresponding to the tasks 1-6 listed above. Your portfolio will demonstrate your ability to apply knowledge of quality practise in the clinical context. The portfolio will form part of a clinical audit which you have undertaken.
This task meets with the external accreditation body (ASAR) quality practice requirements for entry-level sonographers.
Your portfolio will include:
Data presented in figures, tables and diagrams
Short directive paragraphs and objective language
An introduction and conclusion is not required. Recommendations for improvement will relate to specific sections of the portfolio.
Assessment length should be 2000 (maximum) words, excluding reference list, diagrams, tables, graphics, diagnostic report and completed quality improvement tool.
Diagrams can be used to illustrate specific aspects but must be cited and referenced.
The list of references should be contained at the end of the assessment.
Use the American Psychological Association (APA) referencing system.