Leadership, Governance and Culture

Why am I doing this assessment?

This assignment will help you to understand and demonstrate the following unit learning outcomes (ULO):

  1. Critique best practice principles for governance in the clinical environment.
  2. Explain the roles of nurses and other health professionals in implementing quality improvement methodologies.
  3. Examine how the National Safety and Quality Health Service standards govern clinical practice.

Assessment Task Instructions

The assessment instructions have been designed to enable you to understand what is required to succeed in this assignment.

The aim of this Assignment is to use a quality improvement methods and clinical risk management frameworks to provide a report detailing your recommendations for a change in practice.

  • Step 1: Read the attached. Note that this incident occurred prior to the implementation of the National Safety and Quality Health Service (NSQHS) Standards as we know them today.
  • Step 2: Undertake a Root Cause Analysis (discussed earlier in this unit), using either the 5 why’s tool or Ishikawa (fishbone) diagram, to discuss the sentinel event and identify possible causes of the event and the situational factors that were present that may have increased the likelihood of such an error occurring
    • Complete and submit the 5 why’s or fishbone diagram template in the appendix, (do not just supply an empty template).
    • In your discussion of this event, you are NOT required to make professional or clinical care recommendations in regards to the actions of the nurses/health care workers involved.
  • Step 3: Complete a literature review based on the findings of your Root Cause Analysis. This will provide evidence for Step 4 where you need to provide two (2) recommendations for change.
  • Step 4: Using the PDSA quality improvement methodology and clinical risk management framework, provide two recommendations for a change in practice which may circumvent such events recurring. 
    • Consider you are writing this report to your manager, safety committee, director etc. to support a change in practice as part of a root cause analysis of a sentinel event.
  • Step 5: Determine if the practice identified in the case study is current and follows best practice guidelines (both NSQHS, RN Standards for Practice and Facility Clinical Practice Guidelines e.g., RPH, SCGH, WACHS).
  • Step 6: Write your report (layout discussed in class). You will need to identify the rationale for your responses based on the material in the modules and the literature. Ensure you include evidence to support your recommendations of any change or clinical improvement processes.

Format and Structure

This is a formal report, and you must follow the guidelines provided below and those in the tutorials and Canvas site:  

  • Title Page ​
  • Executive summary/abstract (max 250 words- non-structured, must be a summary of the entire report, not a replication of the introduction) ​
  • Table of contents​
  • Table of figures (charts and tables) if appropriate ​
  • Introduction/ Background (Approx 300 words)​
  • Literature review (Approx 700 words)​
  • Discussion (Approx 1200 words)​
  • Conclusions (Approx 200 words) ​
  • Recommendations (Approx 200 words)​
  • References ​(APA7th)
  • Appendices ​(eg: copy of the sentinel event, detailed literature search strategy, completed 5 why’s/fishbone tool)

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