Running Head: QUALITY IMPROVEMENT CHART 1 QUALITY IMPROVEMENT CHART 2 Quality Improvement Chart Quality Improvement Activity Schedule Standards Severity of Risk Performance Indicator Level of Performance / Threshold Compliance in Percent Status Plan of Correction Qtr 1 Qtr 2 Qtr 3 Qtr 4 Provision of Care, Treatment, and Services High Risk Provision of care, treatment and service is the core accountability of health care institutions and precisely the surgical department. Proper care means that doctors should take great care while operating on patients and be sure of all the procedures before conducting them. A performance indicator here will be having more patients claiming that they have received proper care and they are satisfied with the services. The level of performance threshold should be 52%. This is the average and performance should not go below this point. 33% 43% 52% 80% Josephine has been experiencing a lot of pain while taking short calls. She has been to many hospital facilities and has not received any ultimate solutions. She visited a personal doctor who recommended an examination of her kidneys. The results of the examination revealed that all of her kidneys was spoiled and needed to be removed. This required a surgical operation. The doctors in removing the damaged kidneys damaged the joint between the urethra and the bladder. Consequently after one month from the time of the transplant of the new kidney she experienced urine leakage through the surgical incision that was made in her abdomen.This delayed the healing of the wound and had to go back for further surgery to seal the leak. This illustrates the risk of damaging the nearby organs while carrying out an operation on the adjacent organ. It is a common risk associated with the surgical operation of organs. The plan for correction in this case involves increment of better services. The doctors should be more careful in their provision of services sot that they do a good job. When doctors offer poor services on surgeries and make mistakes, complications are more likely to develop which may make situation even worse. Ethics, Rights, and Responsibilities High Risk Ethics, Rights and Responsibilities are what guide what the doctors do. When the doctors do not fulfill their responsibilities mistakes are more likely to be made. For the case of Josephine, the doctors did not fulfill their responsibilities and that resulted to some serious problems. A performance indicator for this standard would be having majority of the patients coming for surgery and their problems are solved once and for all without complication developing later. The level of performance threshold should be 52%. This is the average and performance should not go below this point. 33% 43% 52% 80% On ethics, doctors should not go to the operation rooms when they are not sure of what wil.

1. Running Head: QUALITY IMPROVEMENT CHART
1
QUALITY IMPROVEMENT CHART 2
Quality Improvement Chart
Quality Improvement Activity Schedule
Standards
Severity of Risk
Performance Indicator
Level of Performance / Threshold
Compliance in Percent
Status
Plan of Correction
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Provision of Care, Treatment, and Services
High Risk

2. Provision of care, treatment and service is the core
accountability of health care institutions and precisely the
surgical department. Proper care means that doctors should take
great care while operating on patients and be sure of all the
procedures before conducting them. A performance indicator
here will be having more patients claiming that they have
received proper care and they are satisfied with the services.
The level of performance threshold should be 52%. This is the
average and performance should not go below this point.
33%
43%
52%
80%
Josephine has been experiencing a lot of pain while taking short
calls. She has been to many hospital facilities and has not
received any ultimate solutions. She visited a personal doctor
who recommended an examination of her kidneys. The results of
the examination revealed that all of her kidneys was spoiled and
needed to be removed. This required a surgical operation. The
doctors in removing the damaged kidneys damaged the joint
between the urethra and the bladder. Consequently after one
month from the time of the transplant of the new kidney she
experienced urine leakage through the surgical incision that was
made in her abdomen.This delayed the healing of the wound and
had to go back for further surgery to seal the leak. This
illustrates the risk of damaging the nearby organs while
carrying out an operation on the adjacent organ. It is a common
risk associated with the surgical operation of organs.
The plan for correction in this case involves increment of better
services. The doctors should be more careful in their provision
of services sot that they do a good job. When doctors offer poor
services on surgeries and make mistakes, complications are
more likely to develop which may make situation even worse.
Ethics, Rights, and Responsibilities
High Risk
Ethics, Rights and Responsibilities are what guide what the

3. doctors do. When the doctors do not fulfill their responsibilities
mistakes are more likely to be made. For the case of Josephine,
the doctors did not fulfill their responsibilities and that resulted
to some serious problems. A performance indicator for this
standard would be having majority of the patients coming for
surgery and their problems are solved once and for all without
complication developing later.
The level of performance threshold should be 52%. This is the
average and performance should not go below this point.
33%
43%
52%
80%
On ethics, doctors should not go to the operation rooms when
they are not sure of what will be the outcome of the surgery. It
is ethical that they be sure of what will happen and inform the
patient and the people concerned. On responsibility, doctors
should be more responsible and conduct surgeries with full
attention so as to avoid mistakes
Medication Management
Low Risk
Medication management involves prescribing the right medicine
for the patients. A performance indicator for this would be
having the medicine available at the hospital and the patients be
issued these medications by qualified physicians and chemists
who understand how the medications work.
The level of performance threshold should be 52%. This is the
average and performance should not go below this point.
33%
43%
52%
80%
A proper plan to correct this involves providing all medications
at the hospital. Sending patients to go and buy medicine in

4. chemists increases the chances of them receiving poor
medication management. If this services will be offered within
the hospital premises there are higher chances that patients will
receive a higher medication management.
National Patient Safety Goals
Medium High Risk
National Patient Safety Goals has its performance indicators as
handling patient with more care and avoiding as much as
possible the possible risks associated with surgery. This will
involve informing the patients and their relatives well on the
aftermaths of the procedures.
The level of performance threshold should be 52%. This is the
average and performance should not go below this point.
33%
43%
52%
80%
Awareness of the National Patient Safety Goals should be
increased so that doctors are aware of their responsibilities and
the patients are aware of their rights.
The Environment of Care
Medium High Risk
The environment of care has its performance indicators as the
care given to patients after surgery. They should be cared for
until they are fit to leave and the doctors are sure that there are
no complications that will develop later. When more patients
will be observed having successful surgeries and all the
problems dealt with and they go back better than they came in
then the standard will have been achieved.
The level of performance threshold should be 52%. This is the
average and performance should not go below this point.
33%
43%
52%

5. 80%
Awareness of the Environment of Care should be increased so
that doctors are aware of their responsibilities and the patients
are aware of their rights.
References
NSW Ministry of Health (2012). Surgery Indicators Definitions
2012.Health Services Performance Improvement Branch or
Demand and Performance Evaluation Branch. Retrieved from,
http://www.aci.health.nsw.gov.au/resources/surgical-
services/delivery/predictable-surgery/surgery-dashboard.pdf on
May 28, 2015.
Odeta, D., (2002). SOME PERFORMANCE INDICATORS OF
SURGICAL DEPARTMENTS IN TERTIARY HOSPITALS.
THE JOURNAL OF PREVENTIVE MEDICINE; 10 (4): 19-25.
Retrieved from,
http://www.jmpiasi.ro/2002/10(4)/3.pdf on May 28, 2015.
Australian Institute of Health and Welfare for Health Ministers,
(2008). A set of performance indicators across the health and
aged care system. Retrieved from,
http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=644
2471955 on May 28, 2015.

6. Part V: Evaluation
This assignment has two parts.
Part 1:
Quality Improvement program related to Surgery.
Write a 2–3 page evaluation of the quality improvement
program that you have created. This should be the annual
summary of the hypothetical data. Make sure your hypothetical
data are credible.
Part 2:
As you may recall from Week 1, your Course Project was to
prepare a total quality improvement program related to high-
risk area related to Surgery. Continuous quality improvement
covers many areas.
Throughout the course, you have learned about the attributes
that constitute a quality improvement team and what questions
this team attempts to answer. The assignments toward this
project that you completed each week can now be assembled
into a single instructional document.
Make necessary adjustments to your document so that each
segment flows smoothly into the next. Evaluate your project
using the criteria given below.
1 Are the indicators and their measurements appropriate to the
high-risk area? Do the indicators capture the risk?
2 Are the fictional incidents realistic and plausible?

7. 3 Is the filled chart consistent with the fictional incident?
4 Is the plan of correction feasible? Will it prevent the
occurrence of the incident in future?
5 How do you know the plan worked? What measures will you
use to identify effectiveness?
Risk Management
Risk is something that seems to be fluid. You can prevent many
types of incidents
but the facility is still at risk. It is imperative to identify risks
with the aim of preventing
as many of them as possible. As communication lines are
opened and staff feels
free to discuss issues, many risks are brought to light and can
be prevented.
Some trial-and-error is unavoidable in any healthcare
organization, but the goal is
to eliminate as many errors as possible.
Risk management is often thought of in terms of reducing
liability.
One of the key areas that risk managers address is hospital-
liability insurance
premiums. Facilities commonly face the problem of insurance
premiums increasing
from year to year. These premiums are partially based on past
years' claims.
If a facility reduces risk in one year, it may be able to lower
premiums the following
year.
Therefore, it is necessary to monitor risk on an ongoing basis.

8. In addition to hospital-liability insurance, an organization may
shift a part or all of its
liability for an adverse event to a contractor. Take the case of
medical equipment.
If some equipment malfunctions and a patient suffers an injury,
the healthcare facility
is liable. However, this liability may be transferred to the
manufacturer of the
instrument through contract.
Grading Criteria
Analyzed all indicators monitored and measured in the
performance improvement project.
Included specific, realistic hypothetical data to evaluate the
improvement of chosen indicators.
Explained indicators, measurements, and fictional incidents.
Provided valid values in the chart that are consistent with the
fictional incident.
Explained in detail a feasible plan of correction, as well as its
capacity for preventing other incidents.
Presented a structured document free of spelling and

9. grammatical errors.
Cited sources using the APA format.
Risk Management Topic: Surgery
Week 1 assignment for reference only
Surgery is one of the areas of health in which preventable
medical errors and near misses could occur. Additionally, most
of the patients are very encouraged with the results of the
surgery. However, there are some risks that are involved in the
surgery process. It is therefore crucial to understand the
limitations that are associated with the surgery. In this case, I
decided to choose surgery as one of the high-risk areas in my
project because I think it has become a burning issue in the
HealthCare system (Kavaler, 2014). The paper is intended to
identify, classify, and describe the nature of these risks with
relation to the healthcare providers and healthcare facilities. In
this case, the paper will look at different ways through which
wrong-site, wrong-procedure, and wrong-patient surgery can
affect various disciplines.
In some cases, wrong-site errors normally lead into
devastating injuries to the patients in the process if not in the
future. For example, there was an incident whereby a boy was
left psychotic and experienced brain damage at the same time.
These are some of the problems, which occur as a result of the
surgery errors. The errors occur as a result of failure to have
quality management as well as proper risk management
guidelines within the health facilities. Moreover, increased
pressure to turn over operation rooms quickly has interfered
with the patient’s safety. Additionally, there are common
complications that are associated with the wrong- site or wrong-

10. procedure surgery. Some of the postoperative complications
include atelectasis, wound infection, fever, deep vein
thrombosis, and embolism. The risks are vigilant in the first or
the third day after the operation.
Errors are all too frequent in the medicine and in
particular during the surgery. Whenever these medical errors
occur, the healthcare professionals are always there to struggle
with the aftermath (Hollingsworth, 2005). For example, there
was a case whereby a family practitioner and obstetrician
misdiagnosed a viable pregnancy as a result of the miscarriage.
In this case, the thought came that the Doctor’s patient had lost
her child due to the error committed by the physician. This
made him feel both the guilty and angry. Therefore, in most
cases, mistakes committed in the surgery normally have an
emotional impact to the health professionals. In most cases,
they have the tension since there are possibilities that the
mistakes they have committed will be disclosed to the patients.
Most of them are therefore left with adverse emotional
experiences because they elevate themselves to be at the risk of
the lawsuits. Furthermore, surgery errors may as well increase
the risks of depression, suicide, and substance abuse among
various health professionals.
Moreover, there are various risks that are exposed to
the healthcare facilities as a result of medical errors (surgery).
One of the problems is that there is loss of physicians who
might decide to quit their professionalism after the incident.
This is already a liability to the facility and probably quality
improvement of the system might fail (Imhof, 2013).
Additionally, the healthcare facility may experience complete
burnout as a result of the poor results in the surgery. Senior
healthcare agencies might be in a position to understand that the
healthcare operations in the respective organization are not
safer for the patients. As a result also, there is likelihood that
the facility would seduce low number of consumers in the
future.
In the conclusion, emotional impact that occurs as a

11. result of wrong-site and wrong-procedure surgery could adverse
effects. It may limit the success of the healthcare facility and
the satisfaction of the workers, patients and the medical staff.
References
Kavaler, F., Alexander, R. S., & Kavaler, F. (2014). Risk
management in healthcare institutions: Limiting liability
and enhancing care. Burlington, MA: Jones & Bartlett
Learning.
Hollingsworth, S., Primedia Workplace Learning., Trinity
Workplace Learning., & Trinity Healthforce Learning.
(2005). Universal protocol for preventing wrong site, wrong
procedure, wrong person surgery. Carrollton, TX: Primedia
Workplace Learning.
Imhof, M., & Blondel, C. (2013). Malpractice in surgery: Safety
culture and quality management in the hospital. Berlin: De
Gruyter.