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
Executive Summary: Quality & Safety Renaissance (QSR) Initiative
To: Chief Executive Officer From: Special Assistant to the CEO, Head of Quality Improvement Date: October 25, 2025 Subject: Action Plan to Reverse Rising Medical Errors and Hospital-Acquired Infections (HAIs)
Our hospital's recent growth has been paralleled by an unacceptable decline in patient safety, evidenced by a steady increase in medical errors and a critical 25% rise in Hospital-Acquired Infections (HAIs). This trend directly threatens our patients, erodes public trust, and poses an immediate and severe financial risk through non-reimbursement penalties and increased
I propose the immediate launch of the Quality & Safety Renaissance (QSR) Initiative, a six-month, interdisciplinary action plan centered on the Plan-Do-Check-Act (PDCA) Cycle for continuous improvement. The initiative is strategically focused on reducing HAIs (specifically Central Line-Associated Bloodstream Infections or CLABSIs) and improving error reporting by implementing a Just Culture.
The QSR Initiative is fundamentally a value-added health care strategy. By investing in standardized safety protocols and accountability now, we convert projected costs (extended stays, non-reimbursable care) into retained revenue and superior patient outcomes.
Goals: Reduce the CLABSI rate by 40% and medical error incidents by 15% within six months. This plan requires C-suite sponsorship and a commitment to data transparency to transform our organization into a high-reliability learning system.
Action Plan: Quality & Safety Renaissance (QSR) Initiative
1. Identification of Critical Issues and Impact on Quality
The organization is currently facing two critical, interlinked patient safety failures that violate the core tenets of quality health care:
Steady Increase in Medical Errors: This includes errors across the medication cycle, procedural mistakes, and diagnostic delays. These errors directly lead to patient morbidity, prolong their Length of Stay (LOS), and may result in permanent injury or mortality. A high error rate signals inconsistent processes and a potentially punitive culture that discourages reporting, thereby hiding systemic flaws.
25% Rise in Hospital-Acquired Infections (HAIs): The 25% increase in HAIs (e.g., CLABSIs, CAUTIs, SSIs) is the most immediate threat. HAIs are widely recognized as preventable failures of process compliance.
Impact on Quality Outcomes: These events represent clear failures in the quality dimension of safety. They increase patient suffering and mortality rates.
Impact on Value-Added Care: This trend is financially unsustainable. Under current regulations, care associated with preventable HAIs is non-reimbursable by major