Running header: QUALITY IMPROVEMENT PROCESS

Leadership Strategy Analysis on the

Quality Improvement Process
Summer Pike
Ferris State University










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Abstract
For the purpose of this assignment, I correlated it with a project that I am currently
working on at my hospital. The project focuses on the importance of leading a quality
improvement plan through an associate exposure process that is experiencing a few gaps in my
current hospital. An Associate Exposure Collaborative Team was developed and a revised
associate exposure plan was initiated with the goal in mind of our organization being able to
provide the associates with the safest, simplest, compassionate, and most thorough experience
during an associate exposure.
















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Introduction
Health care workers are subject to a lot of different hazards on the job, including needle
stick injuries, blood and body fluid exposure, back injuries, latex allergy, violence, and stress.
While it is possible to prevent or reduce health care worker exposure to these hazards, health
care workers are actually experiencing increasing numbers of occupational injuries and illnesses.
Rates of occupational injury to healthcare workers have risen over the past. By contrast, two of
the most hazardous industries, agriculture and construction, are safer today than they were a
decade ago (Workplace Safety and Health Topics, 2011). This information may come to a
surprise to those who are not in healthcare but for those who do work in healthcare it is an all too
common occurrence.
An estimated 385,000 percutaneous injuries (i.e., needle sticks, cuts, punctures and other
injuries with sharp objects) occur in U.S. hospitals each year (National Healthcare Safety
Network, 2010). The organization I currently work for is no exception to the possible hazards an
associate may encounter while on the job. Most, if not all, hospitals have a policy and process
that they go through when an associate is exposed to blood or body fluids. The current exposure
process and policy at my organization has a few gaps, leaving the process unacceptable and
unsafe for our associates. In order to implement the most thorough, and yet simple, practice I
enlisted the appropriate collaborative team to modify and review the current process.
Collaborative Team
The associate exposure collaborative team includes the following titles and purpose:
LAB Lab plays a crucial role in the timing, collection, processing, and reporting of the source
patients blood work.
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Chief Tech/Laboratory Manager (Lakes Campus)
Clinical Laboratory Manager (Mercy Campus)
Clinical Laboratory Manager (Hackley Campus)
Laboratory Director (All Campuses)
NURSING Nursing has the most associates within the organization and are most susceptible to
the blood borne pathogens exposure hazards. The nursing supervisor will also drive the process
flow with all associate exposures and the Emergency Department after hour process for
exposures. The operating room is another high frequency area for exposures and we have a nurse
who has personally been through the exposure process helping to represent that area.
Nursing Supervisor Manager (All Campuses)
Surgery Lead Nurse (Mercy Campus)
Senior Director for Nursing Services (All Campuses)
Chief Nursing Officer (All Campuses)
HUMAN RESOURCES Human Resources is important in the managing of exposure cases
and reimbursement of charges and time off work, if needed.
Employee Health Specialist/Workers Comp (All Campuses)
Employee Health Specialist (All Campuses)
WORKPLACE HEALTH Workplace Health is the hub that all associate exposures need to
go through. Workplace Health offers immunizations, test results, counseling, and any treatment
that maybe needed.
Director of Workplace Health
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Manager of Workplace Health
Physician at Workplace Health
INFECTION CONTROL Infection Control is the consulting piece to this process. Infection
Control is responsible for making sure the process is flowing appropriately, up-to-date on the
most appropriate treatment, and within regulations. Infection Control is also a second check on
the validation process.
Infection Control Nurses x 2 (All Campuses)
Infection Control Physician
QUALTIY DEPARTMENT The Quality Department is responsible for making sure the
associates are receiving the best quality care possible.
Director of Quality
Medical Director of Quality
EDUCATION The Education Department is another crucial piece in helping to roll out the
changed process to all associates through multiple educational routes.
Education Director
Data Collection
After multiple meetings with the Associate Exposure Collaborative Team, the team
created and/or revised multiple forms to help validate the new process. The forms below are
available to all associates on the hospitals policy and procedures website (Policy Tech) under
Associate Exposure Control Plan (See Appendix A-C). These forms are a guide to help the
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Nursing Supervisor complete the process by using a checklist, order sheet, and a work flow map.
The completed forms are to be faxed to the Infection Control department for validation. All
gaps will be identified and addressed with the team, continuing to meet as needed.
Goals
The goals for the Associate Exposure Collaborative Team are to provide the associates
with the safest, simplest, compassionate, and most thorough experience during an associate
exposure. Specifically, we want all associates to know what to do during and after an exposure,
we hope to have this goal achieved within the next 3 6 months. We also want to make sure the
source patient gets drawn and the results back within 2 hours of exposure, so treatment can be
decided. If the source patient is HIV positive treatment for the exposed person is most vital
within 2 hours of exposure. We expect to have this goal reached within one month on all
exposure cases. Also we want to make sure all of our associates are completing the electronic
reporting form, Unified Associate Incident Exposure (UAIR), so that the specifics about the
exposure is documented and can be reviewed so that the organization can possibly prevent
another occurrence. We are expecting to have one hundred percent compliance with the
completion of UAIRs on all associate exposures within the next 2-3 months. Finally, we want to
make sure all of our associates are being seen at Workplace Health for follow-up, counseling,
treatment, and medicine if needed. We would like all our associates to report to Workplace
Health after an exposure within the next month after education has been implemented.
Implementing Change
In order to implement change we have recruited some vital administrative people on our
Associate Exposure Collaborative Team. By having administrative support we are able to gain a
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piece of relevance within the organization. An even more significant piece to implementing
change is to have the structure of this process be guided by only a handful or so of people, the
nursing supervisors. By limiting the entire process knowledge to the nursing supervisors and a
few other support people we are able to contain the huge demand training would have on a house
wide roll out. There is always a nursing supervisor on 24/7 to contact after an exposure and it
will be their responsibility once notified to follow the process to completion. Another way we
hope to help implement change is to have all of our associates read a brief power point and
answer a few questions to confirm their understanding of the basics (See Appendix D).
Evaluating Movement
By creating a power point we are able to mandate the viewing and track all those whom
have viewed and completed it, validating the information is out in the public. Also, as mentioned
previously, the form that were created will serve as a tool to validate that the process is going
according to plan and if not we are able to easily track the gaps and implement change. When the
forms begin to come back without errors the success of the new process will become most
evident. Consistent communication with the Associate Exposure Collaborative will also be
another way to validate that our goals for the exposure process are being met, as new meetings or
process reviews may arise.





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Appendix A



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Appendix B

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Appendix C

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Appendix D






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References

National Healthcare Safety Network. (2010, April 14). Retrieved from Centers for Disease
Control and Prevention: http://www.cdc.gov/nhsn/hps_bbf.html
Workplace Safety and Health Topics. (2011, May 18). Retrieved from Centers for Disease
Control and Prevention: http://www.cdc.gov/niosh/topics/healthcare/