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1. Written assignment: Leadership in nursing
Written assignment: Leadership in nursingORDER HERE FOR ORIGINAL, PLAGIARISM-
FREE PAPERS ON Written assignment: Leadership in nursingThis assessment requires you
to use information from your assigned readings, the literature and leaders in your
organization to answer the following questions. If you are not currently employed by an
organization, gather information from a nurse leader or quality management
colleague.What are the organization’s quality program goals and objectives?What is the
organization’s quality management structure? If there is not a formal structure, who is
responsible for quality management in the organization?How are quality improvement
projects selected, managed and monitored? Does nursing staff have any input?State if
quality improvement inservice programs are available for staff in your facility and describe
a brief overview of the content.What quality methodology and quality tools/techniques are
utilized? Are they effective? Why or why not? Provide rationale.How are QI activities and
processes communicated to staff? Is the communication effective? How could it be
improved?How does the organization evaluate QI activities for effectiveness? What is the
process when the QI activity is not effective?Provide 2 examples of a QI initiative that has
been effective in your organization. Describe the QI process that occurred. What was the
impact on patient outcomes? Did it result in a change in practice?ObjectivesCorrelate a
model of healthcare performance and quality to your organization.Identify the nurse’s role
in measuring, monitoring and improving health care quality and safety.Discuss terms and
concepts related to health care quality and safety.ReferencesMinimum of four (4) total
references: two (2) references from required course materials and two (2) peer-reviewed
references. All references must be no older than five years (unless making a specific point
using a seminal piece of information) Written assignment: Leadership in nursing Peer-
reviewed references include references from professional data bases such as PubMed or
CINHAL applicable to population and practice area, along with evidence based clinical
practice guidelines. Examples of unacceptable references are Wikipedia, UpToDate,
Epocrates, Medscape, WebMD, hospital organizations, insurance recommendations, &
secondary clinical databases.Textbooks:Leadership and Nursing Care Management,
Elsevier-Saunders, 2013, 5th editionRead Chapters 17,18,26.I included two additional
articles. Only two assigned readings are needed for references- our textbook can be one.
The other two must be peer-reviewed StyleUnless otherwise specified, all the written
assignment must follow APA 6th edition formatting, citations and references. Click here to
download the Microsoft Word APA 6th edition template. Make sure you cross-reference the

2. APA 6th edition book as well before submitting the assignment.Number of
Pages/WordsUnless otherwise specified all papers should have a minimum of 600 words
(approximately 2.5 pages) excluding the title and reference pages.Written assignment:
Leadership in nursingattachment_1attachment_2Unformatted Attachment
PreviewReprinted with permission from Journal of Nursing Care Quality, 2012;27(2):99-
108. J Nurs Care Qual Vol. 27, No. 2, pp. 99–108 c 2012 Wolters Kluwer Health | Lippincott
Williams & Wilkins Copyright Using the Agency for Healthcare Research and Quality Patient
Safety Indicators for Targeting Nursing Quality Improvement Patricia A. Zrelak, PhD, RN,
NEA-BC, CNRN; Garth H. Utter, MD, MSc; Banafsheh Sadeghi, PhD, MD; Joanne Cuny, MBA,
RN; Ruth Baron, BScN, RN; Patrick S. Romano, MD, MPH Quantifying the critical impact
nurses have on the prevention and early recognition of potential complications and adverse
events, such as those identified by the Agency for Healthcare Research and Quality (AHRQ)
patient safety indicators (PSI), is becoming increasingly important. In this paper, we
describe how the AHRQ PSI may be used to identify nursing-specific opportunities to
improve care based on data from the national AHRQ PSI validation pilot project. Key words:
administrative data, adverse event, central line–related bloodstream infection, deep vein
thrombosis, hospital-acquired conditions, nursing-sensitive indicator, patient safety
indicator, postoperative respiratory failure, pressure ulcer, quality improvement, sepsis T
HE AGENCY for Healthcare Research and Quality (AHRQ) patient safety indicators (PSI) are
a set of hospitalization quality indicators that take advantage of readily avail- Author
Affiliations: Center for Healthcare Policy and Research (Drs Zrelak, Utter, and Romano and
Ms Baron), University of California, Davis; Departments of Surgery (Dr Utter), Internal
Medicine (Drs Sadeghi and Romano), and Pediatrics (Dr Romano); and Physician
Consortium for Performance Improvement Measure Testing and Quality Improvement (Ms
Cuny), American Medical Association, Chicago, Illinois. Supported by the US Agency for
Healthcare Research and Quality contract 290-04-0020. The authors declare no conflict of
interest. Correspondence: Patricia A. Zrelak, PhD, RN, Center for Healthcare Policy and
Research, UC Davis Medical Center, 2103 Stockton Blvd, Ste 2224, Sacramento, CA 95817
(pazrelak@ucdavis.edu). Accepted for publication September 10, 2011. Published online
before print: November 2, 2011. DOI: 10.1097/NCQ.0b013e318237e0e3 able
administrative data.1 The PSIs identify 18 potentially preventable adverse events and
complications that patients may experience through contact with the health care system.
Events identified by the PSIs collectively impart a picture of patient safety within a hospital
and may represent occurrences amenable to system-level change. Medical records
identified as having a PSI of interest may then be reviewed for opportunities for
improvement, such as issues related to nursing care. Written assignment: Leadership in
nursingOBJECTIVE The aim of this article is to evaluate opportunities for improving nursing
care related to the AHRQ PSIs identified through detailed review of a national sample of
medical records of patients identified as having at least 1 event of interest, as part of the
AHRQ PSI validation pilot project and a related collaboration with the University 99 JONA •
Vol. 43, No. 10 • October Supplement 2013 S51 Copyright © 2013 Wolters Kluwer Health |
Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 100
JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2012 HealthSystem Consortium

3. (UHC). Information about the accuracy (criterion validity) of the PSIs, based on the same
review process, has been published elsewhere.2-5 METHODS This study was approved by
the federal Office of Management and Budget and by the institutional review board at the
University of California, Davis. University HealthSystem Consortium provided permission to
use data submitted by member organizations. Data collection procedures complied with the
Health Insurance Portability and Accountability Act Privacy Rule provisions for disclosure
of protected health information without subject authorization to a public health authority
[45 CFR 164.512(b)]. Participating hospitals This was a retrospective, multifacility, cross-
sectional chart abstraction study. Two groups of hospitals participated. The first group
consisted of 47 nonfederal hospitals, representing 29 states and various hospital types, that
responded to a call for volunteers through the AHRQ Quality Indicator technical support
listserve. These hospitals reviewed records that met criteria for PSI 13 (postoperative
sepsis) or PSI 7 (selected infections due to medical care; now known as central line–related
bloodstream infection or CLRBSI).4,5 The second group included 34 academic medical
centers affiliated with UHC, identified through the UHC listserve. Their staff reviewed
medical records meeting criteria for PSI 12 (postoperative deep vein thrombosis or
pulmonary embolus or DVT/PE); PSI 11 (postoperative respiratory failure); and/or PSI 3
(decubitus ulcer; now known as pressure ulcer).2,3 Instrument development Evidence-
based data abstraction instruments and corresponding guidelines, available at
http://qualityindicators.AHRQ.gov/ validationpilot.aspx, were developed by study
investigators based on a literature review S52 and input from national experts. Group 1
instruments were pretested at hospitals in Sacramento, California. Final abstraction tools
included questions about demographic characteristics, verification of the reported events,
patient-level risk factors, preventive measures, evaluation and treatment, and patient
outcomes. Instruments used by group 2 were developed similarly, except a national
steering committee was formed for each PSI, and pretesting occurred within UHC. Data
collection Group 1 hospitals applied a modified version of the AHRQ PSI Windows software
version 3.1 (March 12, 2007), provided by the authors, to extract concurrent probability
samples of records that met criteria for each PSIs under study between October 1, 2005, to
March 31, 2007. Sampling targets included 240 cases nationally and 30 cases per hospital
for each PSI. Written assignment: Leadership in nursingThe overall number of abstracted
records often fell short of the target because some hospitals had no qualifying or retrievable
cases. For group 2, the UHC coordinating center, using the public use version of the same
AHRQ software, prepared the sample list for each study hospital with targets ranging
between 30 and 60 cases per PSI per facility. For both groups, if after answering an initial
set of questions, the patient did not appear to qualify for the targeted PSI event, the
abstractor was allowed to exit the abstraction process. Criteria for each PSI are defined in
the AHRQ PSI Technical Specifications (currently available at http://
www.qualityindicators.AHRQ.gov/Modules/ PSI_TechSpec.aspx).1 Abstractors for each
group were trained via Web-based teleconferences. Group 1 abstractors used a paper tool,
which was submitted to study staff for data entry. Group 2 entered their data into an online
database. Ongoing support was provided by e-mail, listserve, and telephone. Statistical
analysis SAS, version 9.1 (Cary, North Carolina), was used to perform descriptive analyses.

4. Proportions were calculated for categorical data and JONA • Vol. 43, No. 10 • October
Supplement 2013 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams &
Wilkins. Unauthorized reproduction of this article is prohibited. Using AHRQ PSI for
Targeting Nursing Quality Improvement averages for continuous data. Only records found
to have the PSI of event of interest were included in the results. RESULTS Participating
hospitals reviewed a total of 2293 PSI events. Cases per indicator are as follows: CLABSI (n
= 130), sepsis (n = 67), respiratory failure (n = 548), DVT/PE (n = 314), and hospital-
acquired pressure ulcers (HAPU) (n = 1234).2-5 Central line–related blood stream infection
At the time of the study, this indicator included all vascular device types, although most
confirmed events were related to central venous catheters (CVC) (n = 72), followed by
peripheral intravenous (n = 13) and arterial lines (n = 3). Peripherally inserted central
catheters represented 30% of the infected nontunneled CVCs. For short-term nontunneled
CVCs, the internal jugular site was responsible for 34% of the events followed by the
subclavian (25%) and femoral (11%) sites. Femoral catheters had the shortest mean time to
infection (5.7 ± 3.4 days) compared to internal jugular (10.0 ± 6.1 days) and subclavian lines
(11.7 ± 8.4). Abstractors were frequently unable to find documentation of line type
(peripheral vs central) (n = 24), CVC insertion site (n = 12), and CVC insertion or removal
dates (n = 12). Total parenteral nutrition was used in 29 (36%) cases. Abstractors found no
documentation regarding the presence or absence of symptoms in 73 cases. Postoperative
deep vein thrombosis/pulmonary embolus This PSI targets surgical cases that develop a
postoperative DVT or PE. Only 42% of the surgical cases received American College of Chest
Physicians guideline–directed venous thromboembolism prophylaxis before or on the day
of surgery.6 The elapsed time from documentation of clinical signs of DVT and/or PE (eg,
leg swelling, tenderness, or a palpable venous cord for DVT; new dyspnea, chest JONA • Vol.
43, No. 10 • October Supplement 2013 101 pain, or oxygen desaturation for PE) to the
diagnosis or diagnostic evaluation was greater than 1 day in 21% of DVT and 17% of PE
cases. The initiation of treatment was delayed, defined as greater than 1 day from diagnosis,
in 20% of DVT and 17% of PE cases. Postoperative sepsis This PSI targets previously
uninfected patients who develop sepsis after an elective surgical procedure. In a large
number of cases (n = 28; 17%), the abstractor was unable to identify bacteremia,
septicemia, sepsis, or systemic inflammatory response syndrome from the medical record
and in some cases, may have incorrectly assumed that sepsis was absent based on “negative
blood cultures” alone (according to their abstraction notes). Written assignment:
Leadership in nursingWhen hair removal is necessary, clipping and depilatory creams have
been found to result in fewer surgical site infections when compared to razors.7,8 Among
the 67 confirmed cases, only 12 cases had documented hair removal, and razors were used
in 3 cases (25%). Preoperative intravenous (IV) antimicrobial prophylaxis should be given
within 1 hour of incision to maximize tissue concentration (2 hours are allowed for
vancomycin and fluoroquinolones).9,10 In all but 3 cases in which antibiotics were ordered,
administration of the antibiotic occurred within 1 hour of the operative start time. In each
of these cases, antibiotics were administered within 15-minutes of the 1-hour standard.
Pneumonia (54%), CLABSI (46%), and urinary tract infections (12%) were the most
common infections (not mutually exclusive) associated with the septic episode. Optimal

5. antimicrobial prophylaxis (defined as antimicrobials administered within 1 hour of surgery
and stopped within 24 hours of incision time) occurred in 77% in those with urinary tract
infections, 83% of those with surgical site infections, 88% of those with CLRBSI, and 100%
of those with pneumonia.11,12 Perioperative hypothermia (temperature < 96.8◦ F) has
been associated with increased risk of infection and sepsis.8,10 Among confirmed cases of
sepsis, 7 of 31 and 11 of 32 had a S53 Copyright © 2013 Wolters Kluwer Health | Lippincott
Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 102 JOURNAL
OF NURSING CARE QUALITY/APRIL–JUNE 2012 temperature lower than 96.8◦ F in the
operating room and postanesthesia care unit, respectively. In 11.8% of cases, the abstractor
was unable to find a recorded intraoperative temperature, and in 17.6% of cases, the
abstractor reported use of a different temperature scale between perioperative care
settings. Postoperative respiratory failure This PSI is intended to capture cases of
respiratory failure following an elective operation. General anesthesia was associated with
787 of the 834 procedures (94.4%) performed in the 548 records with at least 1 episode of
postoperative respiratory failure. More than three-fourths (80.2%) of study patients
developed respiratory failure within the first week after surgery, with 22.5% reintubated
on the same day as surgery. The most common reasons for postoperative reintubation were
hypoxemia, hypoventilation, and/or hypercapnia (69.8%), followed by airway protection
(20.5%). Of 834 procedures evaluated, explicit documentation of preoperative oxygen
saturation was missing in 287 cases (34.4%), although 80.6% of cases had an American
Society of Anesthesiologists physical status classification of III or IV (indicating severe
systemic disease). In 323 procedures (38.7%), there was no documentation of a PaO2 < 60
mm Hg or a PaCO2 > 45 mm Hg at any time in the postoperative period. For patients who
had a postoperative PaO2 < 60 mm Hg, the median time from the end of the surgical
procedure to the first postoperative event was 50 hours (range; 10 minutes to 42.1 days).
For patients who presented postoperatively with a PaCO2 > 45 mm Hg, the median time to
the first postoperative event was 20 hours (range, 7 minutes to 42.1 days). An order or
protocol for breathing exercises was not apparent in 31% of cases. Pressure ulcer This
measure targets HAPU; it excludes patients with a length of stay of 4 days or less, pa- S54
tients admitted from nursing homes and other acute care facilities, and patients who are
particularly susceptible to pressure ulcers due to paralytic conditions. Of the 1234
confirmed HAPU cases, we found that 96.5% had a skin assessment and 80.9% had PU risk
assessment completed on the date of or the date following admission. There were 152
HAPU cases with an emergency department (ED) length of stay greater than 24 hours, of
which 80.9% had documentation of a first skin assessment completed prior to ED
departure. For cases admitted to a preoperative holding area for greater than 24 hours
prior to admission, 87.2% had a first skin assessment before departure to another inpatient
unit. Twenty-five percent of HAPU cases were not assessed for pressure ulcer risk within
the 2 days prior to the diagnosis. Only 3.6% (median hospital performance) of HAPU cases
included documentation of the location, dimensions, exudate, and site when the ulcer was
first recognized, and only 3.5% (median hospital performance) of cases had these
characteristics documented at discharge. Staging, which is important for deciding on
nursing interventions and treatment, was initially documented in 64.3% of HAPU cases

6. (including ulcers documented as stages 1-4 or unstageable). Stage 3, 4, and unstageable
ulcers represented 20.1% of HAPU cases on diagnosis. Only 13.3% of new HAPUs were
stage 1 when first recognized. Physicians documented the presence of a HAPU in less 50%
of all cases. Staging was documented in 58% (496/850) of HAPU cases at discharge. Height
or weight was missing from 20.6% of HAPU cases, despite a median length of stay of 26
days (range, 5-319). Excluding ambulatory patients, those with a Braden score greater than
18 (low risk), or those with a documented contraindication to turning, less than half
(49.1%) of bed-bound patients were turned or repositioned at least every 2 hours in the 2
days prior to being diagnosed with a HAPU, although most (61.5%) were located in an
intensive care unit on the day of diagnosis. JONA • Vol. 43, No. 10 • Written assignment:
Leadership in nursingOctober Supplement 2013 Copyright © 2013 Wolters Kluwer Health |
Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Using AHRQ PSI for Targeting Nursing Quality Improvement DISCUSSION Potential nursing
opportunities to improve care relevant to the AHRQ PSIs are 103 summarized in the Table.
Common trends across indicators were lack of documentation of an accurate and timely
patient assessment, lack of adherence to national Table. Summary of Potential Nursing
Opportunities as Identified From AHRQ Patient Safety Indicator Pilot Project Patient Safety
Indicator Central line–related blood stream infection (CLRBSI) Postoperative deep vein
thrombosis or pulmonary embolus (DVT/PE) Postoperative sepsis Postoperative
respiratory failure Nursing Opportunities Improve site selection to avoid the femoral vein
for central venous catheter placement (if possible). Evaluate opportunities to reduce
infection related to total parenteral nutrition. Improve documentation of catheter type,
insertion site, insertion date and time, and removal date and time. Document reasons for
catheter placement, ongoing need, and removal. Provide nursing education related to
identification and documentation of signs and symptoms of CLRBSI and associated
interventions. Use AHRQ patient safety indicators to monitor CLRBSI in all acute care units
(not restricted to the intensive care unit). Provide timely implementation of American
College of Chest Physicians directed guidelines for prevention of DVT/PE. Improve
processes of care related to improved recognition of PE/DVT (eg, leg swelling, tenderness,
and/or palpable venous cord and new dyspnea, chest pain, and acute oxygen desaturation).
Improve processes of care to facilitate earlier treatment of PE/DVT. Evaluate opportunities
to use alternative to razors, such as clippers or depilatory agents, when hair removal is
necessary. Administer preoperative IV antimicrobial prophylaxis within 1 hour of incision
time to maximize tissue concentration (2 hours are allowed for the administration of
vancomycin and fluoroquinolones). Improve perioperative temperature management to
include use of the same measurement scale between hospital units (Celsius or Fahrenheit,
but not both) and achievement of normothermia as appropriate for individual surgery (eg,
temperature >36.0 C following colorectal surgery). Evaluate opportunities to improve early
recognition of sepsis and implementation of early goal directed therapy. Evaluate further
opportunities to prevent infection of lungs, blood stream, urinary tract, and surgical site.
Employ strategies to reduce postoperative pulmonary complications in patients with the
following risk factors: poor ASA status, general (vs regional) anesthesia, prolonged duration
of anesthesia (>2 hours), and abdominal, renal, urologic, orthopedic, or emergency surgery.

7. Improve documentation of preoperative and postoperative respiratory assessments to
include oxygen saturation/pulse oximetry. Evaluate opportunities to reduce incidence of
postoperative respiratory failure such as protocols to increase incentive spiratory use and
breathing exercises. Review opportunities to prevent other complications and earlier
recognition of impending respiratory failure. (continues) JONA • Vol. 43, No. 10 • October
Supplement 2013 S55 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams &
Wilkins. Unauthorized reproduction of this article is prohibited. 104 JOURNAL OF NURSING
CARE QUALITY/APRIL–JUNE 2012 Table. Summary of Potential Nursing Opportunities as
Identified From AHRQ Patient Safety Indicator Pilot Project (Continued) Patient Safety
Indicator Pressure ulcer (PU) Nursing Opportunities Accurately assess for and document PU
present on admission. Increase frequency and accuracy of skin and PU risk assessments.
Increase number of patients assessed for skin or PU risk in pre-hospital holding areas and in
emergency department. Include height, weight, and nutrition as part of initial and ongoing
assessments for skin, PU risk, and PU. Aim for earlier recognition of PU and improve on
completeness of PU assessments including PU stage. Take proactive measures to prevent PU
such as turning and repositioning patients, especially in high risk patients. Take steps to
ensure that physicians are aware of their patients’ PU risk and status. Abbreviation: ASA,
American Society of Anesthesiologists. standard …Written assignment: Leadership in
nursing