Assume that you have recently been hired as the special assistant to the chief executive officer (CEO) of your health care organization. Your duty is to head up the new quality improvement department. Over the past year, the hospital has experienced substantial growth but is also facing a number of patient safety concerns, including a steady increase in medical errors and a 25% rise in hospital-acquired infections. Based upon what you have learned in this course, prepare an action plan to present to the CEO with strategies for addressing these issues.
Write a 1,000- to 1,250-word action plan that includes a separate 150- to 300-word executive summary for the CEO. Address the following:
• Identify the issues the hospital is currently facing and how they are affecting quality outcomes and endangering patients.
• Present a detailed plan to improve quality and elaborate on how it aligns with the hospital's initiatives to improve value-added health care. Discuss the quality improvement tool you suggest using to locate and ameliorate problem areas, as well as the roles and responsibilities of involved stakeholders, financial considerations for the implementation of your plan, the goals of the plan, and methods for evaluating its success.
• Describe the effects that the implementation of this plan will have upon administrators, clinicians, and physicians. Explore possible challenges that could arise with stakeholders reacting negatively to changes presented by this proposed plan. What strategies or preventive measures could be put in place to reduce the friction between various health care providers?
• How will your plan improve overall quality for the hospital? How will the improvements your plan suggests implementing now set the hospital up to continue providing quality care in the future? What will happen in the future if nothing is done to correct the current issues?
Sample Answer
INTERNAL MEMORANDUM
TO: Chief Executive Officer (CEO) FROM: Strategic Planning Manager, Quality Improvement Department DATE: October 13, 2025 SUBJECT: Action Plan for Addressing Patient Safety Concerns and Aligning with Value-Added Healthcare
EXECUTIVE SUMMARY
This action plan outlines a strategy for immediately addressing the critical patient safety issues currently facing the hospital: a steady increase in medical errors and a 25% rise in Hospital-Acquired Infections (HAIs). These escalating issues are diminishing quality outcomes, placing patients in jeopardy, and threatening the hospital’s reputation and financial stability.
The proposed solution is the implementation of a rigorous, data-driven Six Sigma/DMAIC (Define, Measure, Analyze, Improve, Control) quality improvement methodology. The primary goal is to reduce the HAI rate by 50% and medical errors by 35% within 18 months. This plan directly supports the hospital's commitment to Value-Added Healthcare by improving patient outcomes and safety while simultaneously reducing costly complications, extended lengths of stay (LOS), and potential litigation.
The strategy emphasizes interdisciplinary engagement, establishing Quality Improvement Teams (QITs) led by physicians and frontline clinicians. Initial financial investment focuses on technology upgrades and focused training, generating a substantial Return on Investment (ROI) by avoiding the significant economic and human cost of preventable errors and infections. Key challenges, such as clinician resistance to new protocols, will be managed through transparent data sharing, shared governance, and empowering clinical staff as QI leaders. This foundational approach ensures a sustainable culture of quality for future growth.
ACTION PLAN: STRATEGIES FOR QUALITY AND PATIENT SAFETY
1. Identification of Current Issues and Impact
The hospital’s rapid growth over the past year has unfortunately outpaced the development and enforcement of foundational safety protocols. We are currently facing two critical, linked patient safety challenges:
Steady Increase in Medical Errors: This includes medication errors, procedural errors, and diagnostic failures.
25% Rise in Hospital-Acquired Infections (HAIs): This primarily encompasses common preventable infections such as Catheter-Associated Urinary Tract Infections (CAUTI), Central Line-Associated Bloodstream Infections (CLABSI), and Surgical Site Infections (SSI).