Leadership for Change and Patient Safety and Quality Improvement

Course Paper Description
Leadership for Change and Patient Safety and Quality Improvement
The course paper is an opportunity for you to explore a specific change, leadership, or
management issue that is of interest and importance to you. You are encouraged to structure
your paper using the Problem, Causes, Alternatives, and Net Benefits (PCAN) approach to
communicating, as described below.
Step 1: Problem identification and description. Identify and describe a patient safety and
quality challenge. What problem will you be trying to solve, and why is it important to different
stakeholders (i.e., patients, healthcare workers, administrators, the general public, etc.).
This can take one of two general forms: 1) analysis of a specific organization, or 2) analysis of
general industry trends and practices. If you currently have professional responsibilities related
to safety and quality, this paper can focus on your particular context and draw from your
experiences and analysis of your organization, much like a case analysis. If you currently do not
have this type of access, you can focus on industry priorities and draw from the literature and
published case studies.
The challenge you address can be technical or clinical in nature or related to workforce or
patient-centered care issues.
Remember: The goal of the paper is to think through how change, leadership, and management
issues impact the current and future states of this challenge. Choose your problem with that in
mind (i.e., where these issues play a significant role).
Sources to draw from:
1. Your own experiences working within a healthcare setting, if you have relevant past or
present experiences. This can use internal data or strategic priorities. Of course, do not
share privileged internal data in your course paper. This is a chance to analyze a
persistent problem in your organization and generate a plan for making progress.
2. Industry sources that help to identify safety and quality priorities:
a. Agency for healthcare research and quality
b. National Quality Forum
c. Joint Commission Patient Safety Alerts
d. ECRI Institute
e. Institute for Safe Medication Practices
Issues to discuss:
• Who does this issue impact, and how?
• What is the nature of the safety or quality challenge? Is it technically complex, resource
intensive, involve patient or staff attitudes or preferences, etc.?
• Is there existing evidence-based strategies or guidelines? If so, are they widely used?
• Is this a new issues or priority, or a long-standing challenge? If new, what has driven
focus on this issue? If long standing, what solutions have been tried to date?
Step 2: Analyze the causes. What organizational issues are driving this patient safety issue?
Explore a change, management, and leadership concepts related to the current state of the
industry (or your organization).
Sources to draw from:
• If analyzing your own organization, interviews with stakeholders
• Reaching out to professionals with experience in this issue
• The research literature
• Industry documents
• Agency for Healthcare Research and Quality Patient Safety Network (e.g., WebM&M
• Robert Wood Johnson Foundation ‘Why not the best’ case studies
Issues to discuss:
• What are the barriers and potential facilitators (missing or not) of change impacting
progress in this challenge?
• What does the leadership structure around this issue look like? Who are the leaders,
what are their roles and functions? What organizational structures influence this
• What types of leadership behaviors have an impact on the current state of this
• Are there management system challenges around this issue?
• Are there accountability system issues involved? Consider goal setting, goal
communication, measurement and feedback, establishing contingencies for meeting or
not meeting goals, formal or informal learning systems, or allocation of time and
resources to priorities.
Step 3: Propose alternatives. What is a better way of addressing this safety and quality
challenge? Here, you are proposing a path to the ‘desired future state’. Based on your analysis,
what would that desired future state look like, and how would you propose getting there? This
can involve new management systems and leadership practices, as well as a process for
implementing these changes.
Sources to draw from:
• Course readings and resources.
• Any research and industry literature related to improving the management and
leadership of safety and quality.
Issues to discuss:
• Are there management system components that need to be introduce or altered in
order to realize improvements?
• Are there leadership practices that need to be changed? New or different structures of
leadership? Leadership behaviors or capacities that need to be developed?
• What is your approach to implementing this change? What are the critical steps or
phases in your process and how would they be carried out?
Step 4: Articulate the net benefits of adopting the alternative. If the world (or your
organization) were to adopt the strategies you’ve proposed above, what would happen? What
does the desired future state look like? Here you are creating the vision of the future that
should drive adoption of your ideas. Don’t forget appeals to ‘hearts and minds’ (i.e., the
rational / deliberative system, and the affective / emotional system).


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