The document presents a comprehensive safety score improvement plan aimed at addressing specific patient safety issues within healthcare settings. It outlines criteria for evaluating nursing leadership, the application of systems thinking, and strategies for gathering and implementing evidence-based practices to enhance patient care. Additionally, it emphasizes the importance of effective communication and adherence to APA formatting standards in the creation of these plans.

1. Safety Score Improvement Plan Scoring Guide Grading Rubric
Criteria Non-performance Basic Proficient Distinguished
Identify a patient safety issue. Does not identify a patient safety
issue.
Identifies patient safety concerns in general,
but does not identify a specific issue.
Identifies a patient safety issue. Identifies a patient safety issue
and explains why the
issue is a primary concern for nursing.
Describe the influence of nursing
leadership in driving needed changes.
Does not describe the influence of
nursing leadership in driving the
needed changes.
Describes the influence of nursing leadership in
general terms but does not describe how
nursing leadership can drive change.
Describes the influence of
nursing leadership in driving the
needed changes.
Describes the influence of nursing leadership as a
driving force for changes that affect patient safety
and quality outcomes, and provides a specific
example of driving a needed change.

2. Apply systems thinking to explain how
current policies and procedures may
affect a safety issue.
Does not apply systems thinking to
explain how current policies and
procedures may affect a safety
issue.
Identifies leadership and structure responsible
for current policies and procedures, but does
not apply systems thinking to explain the
connection to patient safety.
Applies systems thinking to
explain how current policies and
procedures may affect a safety
issue.
Applies systems thinking to explain how current
policies and procedures may affect a safety issue,
and includes a discussion of how staff could monitor
systems and implement safeguards.
Explain a strategy to collect
information about the safety concern.
Does not explain a strategy to
collect information about the safety
concern.
Identifies several strategies to collect
information about the safety concern, but does
not explain one strategy.

3. Explains a strategy to collect
information about the safety
concern.
Explains a strategy to collect information about the
safety concern and how it could be implemented,
and identifies possible obstacles to obtaining
information.
Recommend an evidence-based strategy
to improve the safety issue.
Does not recommend an evidence-
based strategy to improve the
safety issue.
Describes strategies for improving a safety
issue, but does not indicate if it is evidence
based.
Recommends an evidence-based
strategy to improve the safety
issue.
Recommends an evidence-based strategy to improve
the safety issue, and identifies potential limitations
of the strategy.
Explain a plan to implement a
recommendation and monitor
outcomes.
Does not explain a plan to
implement a recommendation and

4. monitor outcomes.
Makes a recommendation, but does not explain
how it will be implemented.
Explains a plan to implement a
recommendation and monitor
outcomes.
Explains a plan to implement a recommendation and
monitor outcomes, and specifies quality indicators
and accountable staff.
Write content clearly and logically,
with correct use of grammar,
punctuation, and mechanics.
Does not write content clearly and
logically, and there are errors in
grammar, punctuation, and
mechanics.
Writes with errors in clarity, logic, grammar,
punctuation, or mechanics.
Writes content clearly and
logically, with correct use of
grammar, punctuation, and
mechanics.
Writes clearly and logically, with correct use
spelling, grammar, punctuation, and mechanics, and
uses relevant evidence to support a central idea.
Correctly format citations and
references using current APA style.

5. Does not correctly format citations
and references using current APA
style.
Uses current APA to format citations and
references but with numerous errors.
Correctly formats citations and
references using current APA
style with a few errors.
Correctly formats citations and references with no
errors.
Print
Safety Score Improvement Plan Scoring Guide
Overview
Write a 3–4-page safety score improvement plan for mitigating
concerns addressing a specific patient safety goal that is
relevant to quality patient care. Determine what a best
evidence-based practice is and design a plan for resolving issues
resulting from not maintaining patient safety.
Quality improvement and patient safety are health care industry
imperatives (Institute of Medicine's Committee on Quality of
Health Care in America, 2001). Effective quality improvement
results in system and organizational change. This ultimately
contributes to the creation of a patient safety culture.
Context
Quality improvement and patient safety are health care industry
imperatives (Institute of Medicine's Committee on Quality of
Health Care in America, 2001). Effective quality improvement
results in system and organizational change. This ultimately
contributes to the creation of a patient safety culture.

6. Questions to Consider
To deepen your understanding, 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 the health
care community.
Consider a performance measurement criteria or best practice
guideline used in your work setting (or one that you are familiar
with).
•How was this criterion or guideline implemented? ◦Has it been
successful?
◦Is it used consistently?
•What evidence-based practices were used in developing the
criteria or guideline?
•How was nursing involved in the criteria or guideline
development?
Resources
Suggested Resources
The following optional resources are provided to support you in
completing the assessment or to provide a helpful context. For
additional resources, refer to the Research Resources and
Supplemental Resources in the left navigation menu of your
courseroom.
Click the link provided below to view the following multimedia
piece:
•Systems Theory and the Fifth Discipline | Transcript.
Assessment Instructions
Preparation
Refer to the library and the Internet for supplemental resources
to help you complete this assessment, a Safety Score
Improvement Plan.
Consider the hospital-acquired conditions that are not

7. reimbursed for under Medicare/Medicaid. Among these
conditions are specific safety issues such as infections, falls,
medication errors, and other safety concerns that could have
been prevented or alleviated with the use of evidence-based
guidelines. Hospital Safety Score, an independent nonprofit
organization, uses national performance measures to determine
the safety score for hospitals in the United States. The Hospital
Safety Score Web site and other online resources provide
hospital safety scores to the public.
Read the scenario below:
Scenario
As the manager of a unit, you have been advised by the patient
safety office of an alarming increase in the hospital safety score
for your unit. This is a very serious public relations matter
because patient safety data is public information. It is also a
financial crisis because the organization stands to lose a
significant amount of reimbursement money from Medicare and
Medicaid unless the source of the problem can be identified and
corrected. You are required to submit a safety score
improvement plan to the organization's leadership and the
patient safety office.
Select a specific patient safety goal that has been identified by
an organization, or one that is widely regarded in the nursing
profession as relevant to quality patient care delivery, such as
patient falls, infection rates, catheter-induced urinary
infections, IV infections, et cetera.
Deliverable: Safety Score Improvement Plan
Develop a 3–4-page safety score improvement plan.
•Identify the health care setting and nursing unit of your choice
in the title of the mitigation plan. For example, "Safety Score
Improvement Plan for XYZ Rehabilitation Center."
•You may choose to use information on a patient safety issue
for the organization in which you currently work, or search for
information from a setting you are familiar with, perhaps from
your clinical work. ◦Demonstrate systems theory and systems

8. thinking as you develop your recommendations.
Organize your report with these headings:
Study of Factors
•Identify a patient safety issue.
•Describe the influence of nursing leadership in driving the
needed changes.
•Apply systems thinking to explain how current policies and
procedures may affect a safety issue.
Recommendations
•Recommend an evidence-based strategy to improve the safety
issue.
•Explain a strategy to collect information about the safety
concern. ◦How would you determine the sources of the problem?
•Explain a plan to implement a recommendation and monitor
outcomes. ◦What quality indicators will you use?
◦How will you monitor outcomes?
◦Will policies or procedures need to be changed?
◦Will nursing staff need training?
◦What tools will you need to do this?
Additional Requirements
•Written communication: Written communication should be free
of errors that detract from the overall message.
•APA formatting: Resources and in-text citations should be
formatted according to current APA style and formatting.
•Length: The plan should be 2–3 pages.
•Font and font size: Times New Roman, 12 point, double-
spaced.

9. •Number of resources: Use a minimum of three peer-reviewed
resources.
Executive Summary Activity
Value: 50 Points
The ability to summarize, paraphrase, and “get to the point” is
an extremely important skill that you need to develop in your
time at School. This assignment gives you a chance to continue
developing your ability to 1) identify key points in a document
and 2) communicate those points to readers in a clear and
effective way.
Now that you have completed your written proposal, you are
being asked to type a 1-page Executive Summary of your team’s
proposal. (You will single-space within the paragraphs and
double-space between them.) This Executive Summary will be
done on an individual basis. You must NOT work on this with
your teammates.
Think of your audience as being the Dallas Regional Chamber
members. They should be able to read your summary and
understand the core of the following:
1) The challenge/need in the community you want to do
something about
2) Your proposed plan to address the challenge/need
3) How/why your plan is going to make a concrete difference in
the community

10. Please note that there is a discussion of writing summaries on p.
279 of your book and an example of one kind of a summary on
p. 332. Please keep in mind though that these pages just offer
suggestions but you need to create your own summary and make
sure that you address “the core” as mentioned above.
Prepare your summary in Word, using 1” margins. At the 1” top
margin, you can center the following:
EXECUTIVE SUMMARY
by Your Name
CRITERIA
Below Expectations
0-3
Meets Expectations
4-6
Above Expectations
6-8
Summary Skills
Summary is very short; key information is missing and minor
details are given too much attention.
Summary is good: key information is restated well and minor
details and author opinions are avoided.
Summary is excellent: all major points are restated clearly and
concisely and minor details and opinions are avoided.
Purpose
Summary does not restate purpose, key arguments, facts, and
figures.
Summary restates main purpose, key points, facts, and figures
well.
Summary restates main purpose, key points, facts, and figures

11. excellently.
Format
Format lacks title and information about the source.
Format includes title and information about the source.
Format includes title and information about the source and both
are stated clearly and concisely.
Organization
Summary’s organization follows no logical or coherent order.
Summary is organized well. Information follows a logical order.
Summary is organized well and invites readers to read more.
Information follows a logical order and creates flow and clarity.
Audience Awareness
Information is not tailored toward an executive-level audience.
Summary teases reader.
Summary is written appropriately for an executive audience.
Information is tailored nicely toward executive audience.
Executives can make decisions and take appropriate action.
Grammar and Mechanics
Significant errors make summary hard to read
Minimal errors exist and do not impede meaning.
Summary is free of grammatical or mechanical errors.
Dear Dallas Chamber of Commerce,
We at Blue Cross Blue Shield of Texas are one of the largest
health insurers in our region. It is our mission to promote the
health and wellness of our members and our communities
through accessible, affordable and quality healthcare. As a
pillar of the Dallas community, it is also our duty to give back
and help the many families who are in need. We already have a
community program set in place called Healthy Kids, Healthy
Families. This program addresses areas in nutrition, physical
activity, disease prevention and management, and supports safe
environments (Healthy). We would like to expand upon our
already existing program and offer aid to children who have
parents that have been incarcerated for drug abuse.

12. Background and Goals
The Texas Department of Criminal Justice reports that children
of offenders have a 70% greater likelihood of becoming
involved in the criminal justice system (TDCJ). In Dallas-Fort
Worth alone 70,000 children have parents who are incarcerated,
so this means DFW potentially has 49,000 future inmates
(TDCJ).
Also, according to the statistics report by DEA FD, powder and
crack cocaine usage has increased due to its high and stable
available market that comes from Mexico. Statistics show that
14% of young people have access and are abusing this substance
(SUBSTANCE). Another highly accessible drug is alcohol, the
primary drug abused in Dallas with statistics showing that 62%
of secondary school students (grades 7 -12) have consumed it,
and 29% had consumed alcohol in the previous month
(SUBSTANCE).
Substance abuse also negatively affects the health care system.
Figure 1 below is provided by the National Institute on Drug
Abuse breaks down the costs different drugs have on healthcare
(Trends). The overall costs due to drug abuse consists of costs
related to crime, lost work productivity, and healthcare
combined. Health care costs alone account for 24 percent of
these overall costs.
Figure 1
As a healthcare insurer these costs are of great concern to us. If
we can reduce the rate of substance abuse in Dallas we would
also be helping our local healthcare system, which is a goal in
our Healthy Kids, Healthy Families initiative.
Through our program Break the Cycle, we want to help youths

13. realize that although their parents have made poor decisions
regarding drug use, they have a choice to not follow that path.
There are many programs that help teens who are already in the
juvenile detention system due to drug abuse. For example, The
Dallas County Juvenile Department offers many services such
as clinical, educational, institutional, and probation services
(Dallas). Although our goal is to prevent youths from drug
abuse and future incarceration, The Dallas County Juvenile
Department services offered a great template for our program.
Thier services gave us an idea of what kind of professionals we
should employ, counseling services to provide the families, and
what kind of background check should be run on our volunteers.
The program we are proposing is important to us because two of
our members grew up in families with parents who have a
substance problem. They both expressed that a program like this
would have made a big difference in their lives, such as keeping
their grades up, and helping them evaluate their own self-worth.
Having a substance abusing parent is like having a ticking time
bomb in a home. One of our members, Kathryn, never knew
when her mother would be stopping by to see her and never
knew where she was. All she knew was that her mother always
looked and acted differently on the rare occasions that she
would see her. Broken promises and scary arguments caused
depression in Kathryn’s life at such a young age. She never had
a chance to experience life in a normal family and had always
wondered why her mother did the things that she did and never
wanted to come home. We hope our program can break this type
of cycle and prevent these children from repeating their parents
mistakes, gain self-worth and help them understand that no
matter what pressures they may face drug use is not an option.
Proposed Plan
According to the National Council on Child Abuse and Family
Violence, “Parents' abuse of alcohol and other drugs can lead to

14. a cycle of addiction, which is reflected by high rates of
alcoholism and other substance abuse among children of
addicts. Substance abuse among youth leads to a domino effect
of problems in school, involvement in juvenile justice, teen
pregnancy, and mental and emotional turmoil” (Parental).
Through our Break The Cycle program we are determined to
prevent youths from following existing bad habits in their
homes. Our program targets children in middle school who have
parent(s) or guardian(s) that have been or are currently
incarcerated because of substance abuse. We will give these
children an opportunity to see that they can take control of their
own lives and decisions when it comes to drugs.
As found by the editors of Children of Substance-Abusing
Parents, “Consequently, in a family in which one of the
members becomes a substance abuser, profound and significant
implications for the rest of the family can be anticipated as
familial roles are shifted and generational boundaries are
crossed. For example, as a substance-abusing parent becomes
unable to fulfill his or her role, other family members, including
the children, may begin to fill the existing vacuum and assume
the missing parental roles and responsibilities, often at the
expense of their own development” (Straussner). The vision of
our program is to fill the emptiness that the children may feel
inside due to an absent parent. Staff can do this by sharing
knowledge about drug use and using encouragement with the
group of students that they work with to make them feel like
their lives still matter and their only job is to be a kid.
Children of Substance-Abusing Parents also mentions that when
a parent is addicted to drugs, “the child is essentially parentless
and likely learns to take care of himself or herself.
Unfortunately, depending on the child’s age, he or she may
become a ‘parentified child’, who becomes a caretaker of his or
her own parents and siblings even at the cost of his or her own
development” (Straussner). We wish to become role models for

15. these children and let them know that they are not alone.
Our program will serve 100 students using 12 counselors and 10
volunteers. Flyers will be sent to high school student
organizations to request volunteers and offer community service
hours that are required for graduation. Background checks will
be administered on everyone on the staff team, including
volunteers. Our program will take place on Saturdays from
10:00a.m. to 4:00p.m. and will include lunch for everyone. We
request that the volunteers and staff come early to set up
lunches and activities for the day. To join our program it is up
to the parents or current guardians of the children to sign them
up. This shows that the parents involved in substance abuse are
willing to better the lives of their children and it can show
responsibility roles by the parent if they decide to mention this
program in court.
The flyer in Figure 2 will be sent to the students of Thomas C
Marsh Middle School, Medrano Middle School and Edward H.
Cary Middle School which are in the well known drug
influenced neighborhood located, near Webb Chapel Rd., Marsh
Ln., Royal Ln. and Forest Ln. Flyers will also be sent to Child
Protective Services and the Dallas Police Department serving
the specified Dallas area.
Figure 2
Break The Cycle is completely non-profit and it is free to all the
students who join. Edward H. Cary Middle School is our chosen
destination for the program to take place and we have decided
to provide transportation using buses to and from the nearest 3
middle schools mentioned above. Students will be split into
several groups in a five to one student:counselor ratio. These
groups will rotate to different stations throughout the day so
each student experiences the most from our program. As the

16. flyer above indicates, the students will then be involved in
several activities that build teamwork, self-worth, confidence,
responsibility and ethics which are traits they may not be able
to learn from their drug abusing parent(s) at home. These
activities include: arts and crafts, sports, games, group
counseling, and drug awareness speeches. Students wanting
assistance in homework are also encouraged to bring their
school work to participate in an optional tutoring station. If any
additional one-on-one counseling or parent-child counselling is
desired by the student or parent, our professional counselors
will be available Tuesday through Friday for private
appointments. We believe that it is important for these students
to know that having a substance abusing parent is not their fault
and addiction is not an easy illness to overcome. In addition, we
will focus on the risks, consequences, and side effects of using
drugs as well as the difficulty to withdraw from current drug
using.
The primary goal of Break the Cycle is to lower the Dallas
statistics of children following their drug addicted parent’s
footsteps and for them to understand that being drug free is the
best option. Therefore it will lead to less youths being
incarcerated for substance abuse which means saving the futures
of many generations. With the program being only on Saturdays
during the school year we wish to expand it to the summer time
as well, taking place on Wednesdays and Saturdays. Our focus
is to make a positive influence on these young students before
they begin their journey through high school where drugs and
influences can become part of everyday life.
2016 Schedule
Below is a brief outline of the schedule if Break The Cycle is
approved by July of 2016
· Send flyers out within the first week of school
August 22

17. · Deadline for parents to sign up
September 12
· School Year Program Begins
September 17
· School Year Program Ends June
3
· Send flyers out for summer registration May 22
· Deadline for parents to sign up (summer)
June 5
· Summer Program Begins June 12
· Summer Program Ends August 5
Staffing
To help plan all of our activities and events, we will be bringing
on a full time project manager, who will be in charge of running
our drug prevention program. This project manager would
handle everything from getting in contact with volunteer
services to finding volunteers, to getting the program prepared
for feeding over 100 kids in the program a nice, healthy
Saturday lunch. They would also be in charge of more important
things such as getting the background checks on all of the staff,
as well as on all of our volunteers. We would also bring on two
full time and ten part time certified counselors who would work
directly with these children to ensure that they are on the right
path at home, in school, and most importantly, in life. The full
time counselors would be available Tuesday thru Friday for any
additional counseling that any child would need during the
week. Our program would also bring on many volunteers,
mainly high school students with the ability to relate to the
children, also to help prepare the food during lunch for the 100
children. They will additionally help prepare the many activities
for the children to be engaged in. Lastly, we would employ two
school bus drivers to run routes for our program on Saturdays to
help bring all of these children together, and even bring them
all home at the end of the day.

18. Budget
Our research has shown that the annual budget of running drug
prevention program for minors is around $300,000 based on
Virginia's existing programs and according to West Virginia
Department of Health and Human Resources Bureau for
Behavioral Health and Health Facilities, “Substance Abuse
Prevention Program” (Substance). The tables on the following
pages show the individual costs of each of the components
needed. We also have 10 volunteers. However, they are not
considered in the costs. The office space (LoopNet), bus rental
cost (Bus Results) and bus driver cost (Salary.com) were found
online.
Table 1: The total cost during the school year is $168,414 as
shown in the table below.
Table 2: The total cost during the summer is $72,778 as shown
in the table below.
The total cost for the whole year would be $241,192.
As shown in Figure 3 below, we plan on getting 60% of the
funds from Blue Cross Blue Shield and 40% of the funds from
other donations, such as fundraisers and events.
Figure 3

19. Conclusion and Authorization
As seen above, this program Breaking the Cycle is there to
ensure that the children of Dallas and the community at large
remains drug free. This will be done by educating and
counseling those children on the importance of remaining drug
free rather than following in the footsteps of their addicted
parents. The children will receive counseling sessions and will
also be involved in different activities to help them build
various good traits that will help them in school and in society.
The city of Dallas is in great need for such a program with rates
of drug related incarcerations being higher than surrounding
cities. This is why Blue Cross and Blue Shield of Texas, with
the help of fundraisers and other donations, offers this program
free to the students and families in need. We hope that the
absence of fees encourages parents to enroll their children into
this program and as a result our program will grow and expand
in years to come. It is known that the youths of today are the
leaders of tomorrow and thus it is key that we invest in them by
ensuring they stay off drugs that may ruin their future. We all
know the effects that drugs have on a person, his or her family
and the community at large. Thus investing in these children
whose first role models have indulged in drug activities will not
only help them as individuals but also help the city of Dallas at
large.