Week 7: Quality Management and Control

SLMC has a continuous commitment to delivering the highest quality care by addressing crucial issues, such as patient safety, technology, and expanding services to meet community needs. As the nurse administrator, you determine an audit of elderly patient readmissions would be helpful data to be gathered. Discuss some of the specific information you would include on this tool and how specifically you would proceed with this project and your rationale for including them in the tool. Whom would collect the data?

After reading about Deming’s 14 Total Quality Management principles, state one management principle you would apply to assist in delivering the highest quality care?

Scholarly references to support your response are required.

Week 7: Introduction

Table of Contents

Welcome to Week 7!

This week, we will focus on quality standards and controls relating to the nurse administrator. As a nurse executive, you want to engage and empower your team in a culture of continuous quality improvement and safety. Let’s get started.

Course Leader Week 7 Introduction

i welcome to NR five three one the week 7 recording this is Dr Diana Meeks the course leader and welcome I am pleased that you got two week seven so you are almost finished the course and if you have not done so you’re getting ready to submit your last assignment so great work one thing I just like to refresh we last spoke are around week five week six six I’d just like to recap that you focused on socialization and educating your staff and with a focus on team building building your team and creating your team are key things that as a nurse leader that you that you will be doing regardless of what area you work in and then also organizational interpersonal and group communication communication is so vital and so critical with your team and with you and their team and of course communicating with patients and the community and other interdisciplinary that you begin to work with that to be working with and then also delegation delegation of various tasks by your direct reports or by.


Just the staffing model of who works with whom on the various units so lots of things during week six to focus on as a nurse leader and week seven you’re going to be looking at quality controls and reviewing information but with a specific focus on sustaining achievable outcomes as a nurse leader there’s a lot of outcomes that your going to be.


Having to keep track reporting various reporting measures and a lot of them are tied into financial incentives as well so a lot of information too to be aware of as a nurse leader now your last assignment is the executive summary and this is to. Really articulate the results of a magnet report now there is no magnet report that’s prepared for you this is where you can do a search you may have one that you’ve used in within your organization but you’re going to be utilizing the results are sharing the results in a favorable light if you will to the board of directors or you can change it and some items to work on with your team so really looking for.

You to share the information utilizing one of the magnet model components and specifically to the board of directors so this is a skill where you have to take a huge report and narrow it down and write a very concise an executive summary of this report pulling out information that you as a nurse leader feel is important to share with the board of directors so you do have a lot of flexibility and a lot of leeway there will be a webinar are the focuses on this last session if you have not attended or viewed the recording and I would encourage you to do that so this is kind of a fun assignment the lots of students who really enjoy doing this because you can do bullet points you can do a narrative and there’s various examples so you can also tease out the key pieces that you want to include in that so it is fun that most of the students do share that.

So anyway welcome again to week seven Keep up the great work next week is a short week and we’re just going to be doing a wrap up and so I hope you’ve been listening to that so thanks again for listening and I hope you have a great rest of your day thank you.



Evaluate organizational theories in relation to healthcare administration utilizing critical thinking and collaborative therapeutic intervention strategies of the professional role. (PO5)

Weekly Objectives

  • Create therapeutic intervention strategies to be used in an executive summary format.
  • Discuss selected therapeutic intervention strategies within in an executive summary format.


Synthesize management and leadership theories with her/his strengths in preparing for nursing administrator roles; utilizing critical thinking, communication skills and therapeutic intervention strategies, of the professional role. (PO 3)

Weekly Objectives

  • Evaluate the use of management and leadership theories to communicate information in an executive summary.
  • Evaluate quality of care through the application of management and leadership theories.


Compare and contrast the effect of organizational structures, e.g. organizational charts, standards, philosophy, procedures, and culture on work processes and organizational and patient outcomes; utilizing critical thinking, communication skills and therapeutic intervention strategies of the professional role. (PO 8)

Weekly Objectives

  • Determine the effect of organizational structures and communicate strategies in an executive summary.


Apply the use of research in the evaluation of healthcare outcomes; utilizing critical thinking skills, and research strategies. (PO 2)

Weekly Objectives

  • Apply research in the evaluation of quality control and quality management healthcare outcomes.


Examine effective verbal and written communication; utilizing communication skills of the professional role to promote and improve quality and safety in healthcare. (PO1, PO2, & PO5)

Weekly Objectives

  • Examine quality of patient care through written communication to improve healthcare.

Week 7: Reading

Marquis, B. L. & Huston, C. J. (2017). Leadership roles and management functions in nursing: Theory and application (9th ed.). Philadelphia: Lippincott Williams & Wilkins.

  • Chapter 23: Quality Control

Roussel, L., Thomas, P., & Harris, J. (2016). Management and leadership for nurse administrators (7th ed.). Burlington, MA: Jones & Bartlett Learning.

  • Chapter 14: Leaders Achieving Sustainable Outcomes


Giesbers, A., Schouteten, R. L., Poutsma, E., van der Heijden, B. I., & van Achterberg, T. (2016). Nurses’ perceptions of feedback to nursing teams on quality measurements: An embedded case study design. International Journal of Nursing Studies, 64, 120-129. doi:10.1016/j.ijnurstu.2016.10.003

Laird, E. A., McCance, T., McCormack, B., & Gribben, B. (2015). Patients’ experiences of in-hospital care when nursing staff were engaged in a practice development programme to promote person-centredness: A narrative analysis study. International Journal of Nursing Studies, 52(9), 1454-1462. doi:10.1016/j.ijnurstu.2015.05.002

Week 7: Lesson

Table of Contents

Nursing Administration Controls


As we begin this week’s lesson, we will focus on quality standards and controls the nurse administrator may utilize to engage and empower the team towards a culture of continuous quality improvement and patient safety.

Quality Management

As the nurse leader within a healthcare organization, the American Nurses Association (ANA) (2010) Nursing: Scope and Standards of Practice, is one resource that is beneficial to become familiar with as it offers guidance and a foundation for nursing leadership practice. It is essential as a nurse leader, to become familiar with the various ethical principles, business ethics, the American Nurses Association (ANA) Code of Ethics, and the Patient Bill of Rights to assist in advocating for your patients, staff, and the nursing profession. This knowledge can also assist the nurse leader in developing a specific culture for the organization.


Time to reflect…

What challenges could you experience as you adopt a culture of continuous quality improvement and a culture of safety? Review Display 23.3—ANA Scope and Standards of Practice, (Marquis & Huston, 2017).

Listen to these reflective thoughts from the Course Leader:

Hi this is Dr Diana Meeks and this is our time to reflect what challenges could you experience as you adopt a culture of continuous quality improvement and a culture of safety what I’ve asked you to do is to review display twenty three point three in your textbook the ANA scope and standards of practice and that’s in the Marquis and Huston book so please review that and that shows you the scope and standards the practice for an nurse administrators so review those reflect on those and consider some of the challenges that you may have would it be a financial challenge would it be a space challenge would it be a staffing challenge supply challenge interdisciplinary various things that you may consider you know their regulations and things of that nature so reflect on that for this particular one thank you so much.

A standard is a level of excellence predetermined by a set authority and is typically objective, measurable, and achievable (Marquis & Huston, 2017). There are a variety of standards, and the organization determines which standards will be adopted to support and guide the care provided. As a leader, you may have an opportunity to decide which standards you will focus on to achieve your desired level of quality care and/or patient safety.

Various tools can assist the nurse leader to manage the quality within a facility. One example of quality monitoring is an audit which typically addresses a specific desired outcome, its process, and/or the organizational structure issue. The outcome audit is generally conducted to determine the result of a designated nursing intervention and indicates the general quality of care. Some examples include the mortality rate or length of stay for a particular organization (Marquis & Huston, 2017). Many organizations are now employing informatics nurses to assist the organization with the many aspects of technology and training of team members. They could also assist in the retrieval of data to assist with an audit.

Time to reflect…

As the nurse leader, in evaluating and prioritizing outcomes of care delivery.

Listen to these reflective thoughts from the Course Leader:

Hi this is Dr Diana Meeks and this is our time to reflect as a nurse leader and evaluating and prioritizing outcomes of care of delivery just reflect on that for a few moments you have many different departments or areas in the facility that you would have oversight but there is a wide range of care that would be required for patients and to take each unit at one individual and you know examine the patient examine the type of patient the care required look at the model.

Patient care delivery that you would really need to make of benefit for patient care look at your staff mix and then also on the other thing to consider when you’re prioritizing is sometimes insurance or funding will have an issue in how to place your patient the discharge plan and working with the discharge planners or a social worker and things of that nature but there’s a lot of things to consider and of course your overall budget for a specific area the other thing too that looking out priorities for your facility looking at possible growth opportunities are looking at areas to change various products that you offer to add or delete certain ones.

Those just a couple things to keep in mind as you reflect on the issue and the particular topic this is our time to reflect Thank you.

When monitoring a process outcome, typically a task is reviewed to determine if documentation exists to support that it was completed. Checking a patient chart to determine if a patient received discharge instructions or determining if the patient’s medications were reconciled at discharge are two examples of a process outcome. Process and outcome measures are a great way to help maintain a culture of continuous quality improvement.

Some structure-outcome elements are determined by accreditation or licensing bodies; for example, there may be set criteria for staffing ratios and staffing mix on a particular area that must be followed. Documentation of schedules should reflect this outcome element. Translating the results of the data retrieved and including in necessary benchmarks may be required at various levels within the organization.

To ensure the highest level of care provided, quality controls should be an ongoing process and not simply a reaction to an event. When an unforeseen event does occur, some organizations will conduct a root-cause analysis (RCA) with all the departments involved to help determine the cause of the event. After the cause of an event is determined, recommendations, and oftentimes policy or other changes, will be implemented to hopefully prevent a repeat of a similar event. As the nurse leader, participation on this committee is highly recommended to reinforce your support of quality within the organization.

Time to reflect

As a nurse leader, how can you create a culture to encourage the reporting of untoward events or errors?

Listen to these reflective thoughts from the Course Leader:

Hi this is Dr Diana meats and this is our time to reflect as a nurse leader how can you create a culture to encourage the reporting of untrue or. Events or errors depending upon your organization and what template you you may have a committee where if there is medication errors if there is errors were this gets brought forth to the committee and it’s reviewed by an interdisciplinary team and so whenever there is an error then certain parties could be there whether it’s a pharmacist if it’s a drug error then a unearths and a nurse manager or director at that could be a nutritionist you know various persons that supply why a person physician so get a team together to reflect on errors now also depending upon the culture if you want to encourage folks to you know your team to report errors them you’re going to have to have in place that if there is an error how do you handle that from a disciplinary standpoint will the person be fired will they be written up how will that be handled.

Some organizations say if you report it it’s OK you know nothing will occur where depending upon the severity if a patient dies then there may be an issue there so really kind of you know talk with your legal folks you know talk with other you could talk with other peers other organizations and really get a sense for how you would like to adopt that and move forward also I would encourage you know you to research what I would care what.

Other organizations may also be doing in the area this is our time to reflect Thank you.

Quality Control

Various quality-control measures exist in organizations to monitor and measure set quality standards or benchmarks. As the nurse leader, the designated person must be held accountable for a specific measure and ensure continued monitoring and follow-up occurs to maintain quality standards. According to the Institute of Medicine (IOM) (1994), healthcare quality is the degree that health services for individuals and populations align with the desired health outcomes. However, oftentimes the definition of healthcare quality may differ between patients and healthcare providers. It can be a challenge to the nurse leader to help facilitate a common understanding of healthcare quality for all persons involved in a situation. Many organizations have a designated quality assurance department to assist with the oversight of the various quality improvement and safety issues within an organization.

In an effort to support quality improvement, the Robert Wood Johnson Foundation (RWJF) and the Institute of Health (IHI) have funded various initiatives around the country to support quality-improvement projects (Marquis & Huston, 2017). They recognized the importance of quality outcomes in patient care.

Quality control information provides employees feedback about the care they provide to their patients. This quality-control data is often used by other entities for quality monitoring. Once a set standard or criterion is established and the information to be collected or monitored is determined, education needs to occur so employees are aware of the standard, process, and expectations for their role in the standard. After a designated amount of time, if employees are not following the set process, corrective action may be taken. Coaching, a write-up of the incident in their file, or termination, depending upon the event or severity of the incident may occur. These corrective-action steps must be clearly outlined in writing for all personnel.

Time to reflect…

As a nurse executive, what strategies could you utilize to engage and empower your team in a culture of continuous quality improvement and safety?

Listen to these reflective thoughts from the Course Leader:

Hi this is Dr Diana mix and this is our time to reflect as a nurse executive what strategies would you utilize to engage and empower your team in a culture of continuous quality improvement and safety and at our previous time to reflect we talked about encouraging the reporting of any errors that way you can track them you can try to resolve them and try to prevent them from occurring again and also considering to have a non-punitive.

I guess reporting system so if an employee with to report something they would not be punished or risk losing their job I know I have and you know in some situations I’ve heard member say team members nurse to say that they don’t want to say if they’ve committed an error because they might be fired and they need their job so that’s something certainly to consider and the other also to consider you know again if you are a magnet organization or if you’re working on that or if it’s something you want to create You could have a safety committee as well and encourage input from from staff.

And also input from you know various other department also too what some organizations may do you would they can have a clinical ladder is a program or a program where nurses can move up the ranks or or gain points or maybe get an increment raise based upon certain criteria but one thing could be that if they do contribute to research regarding quality to certain chart audits and things of that nature there could be a very a list of certain things that if a nurse was to do take you know three of these and they can get like.

A kind of a certain percentage increase or they get they could help them move up and ranks so to speak if they’ve got a clinical ladder program in place or something similar to that it doesn’t have to be named that those are just a couple of you know things to consider in our time to reflect Thank you.

Quality Patient Care

Various models to promote and improve quality patient care may be utilized within healthcare organizations. Two quality-improvement models include Total Quality Management (TQM) and the Toyota Production System (TPS) (Marquis & Huston, 2017). The focus of quality improvement is an ongoing attempt to continuously improve quality.

As a nurse leader, it is important to be familiar with various monitoring agencies involved with your organization. In 1984, The Joint Commission—a nonprofit, independent organization that accredits healthcare organizations and programs in the United States—mandated quality controls must be in place to promote assurance of quality patient care. In addition, the core-measures program and the National Patient Safety Goals (NPSGs) have been implemented by The Joint Commission to promote improvements in patient care and safety within healthcare settings (Marquis & Huston, 2017).

The Centers for Medicare and Medicaid Services (CMS) also set standards for measuring quality healthcare. Process changes in required reporting, monitoring, and reimbursement information for various agencies can have an impact on organizations in a variety of ways that may affect the organizational processes, structures, and outcomes.

Some additional influences on healthcare quality and safety include Six Sigma and the Leapfrog Group. The IOM (2001) released a report, To Err is Human: Building a Safer Health Care System in the 21st Century, and stated goals to assist with improving quality and safety in healthcare environments. The plethora of quality-and-safety resources available can be overwhelming. However, developing a strategic approach with ongoing monitoring, reporting, follow-up, and reevaluation can be helpful, once a process has been implemented, to ensure targets and goals are being met.

Time to reflect…

Consider how improvements may be made regarding National Patient Safety Goals and core measures at your current organization. What would you do differently as the nurse leader?

Listen to these reflective thoughts from the Course Leader:

Hi this is Dr Diana Meeks and this is our time to reflect consider how improvements may be made regarding a National Patient Safety goals and core measure of at your current organization what would you do differently as a nurse leader Now keep in mind that an executive summary may be a great way to share this information but with regards to the National Patient Safety goals review those as a nurse leader it is imperative that you are aware of those you know those will need to be monitored to your You’ll need to be probably collecting data reporting data and most organizations have a designated Patient Safety Department patient safety officer and oftentimes there’s the committee as well that you pull in various individuals from you know have a representative from all the departments to get input regarding that So look at your current organization inquire or interview meet with them ask them what they’re doing and ask them if they would change anything with a improve anything that’s a great great way to you know collect information so that you know if you’re not already a nurse leader when you are a nurse leader that you know you can kind of have those that information kind of in your back pocket and you can decide if that’s something that you’d like to you know initiated as well so so keep that in mind and if you’re not currently working at an organization then reflect upon a former organization that you may have worked or talked to you know someone who worked at another organization and gather information also you could do some research you know review articles review information and you know see what information you can collect and then be able to reflect on this with our time to reflect Thank you.

Executive Summary

As we discussed last week, the nurse leader will need to communicate with their team and other individuals for a variety reasons. After a visit by an accrediting or other agency, an overview or specific details of a lengthy report is helpful to share information to persons who may not have time to read the whole lengthy report, such as a Board of Directors or a Chief Executive Officer (CEO). An executive summary is a written, nonverbal means of communication used to share concise information related to a specific topic. This summary provides an overview of a larger document to assist the reader to determine if they would like more information or would like to read the entire document. There are specific elements an executive summary should include; however, it is essential the summary explains these three points: why the document was written, your recommendations and conclusions, and any financial considerations. Only the most significant points to support the stated conclusions from the original document are shared (Roussel, Thomas, & Harris, 2016). Examples of executive summaries are provided in your textbook.


This week, we explored quality management, specifically related to nursing-administrator controls and developing a culture of quality patient care and safety. Next week, we will reflect on the last 7 weeks of the course and offer feedback to our peers regarding their executive summary project.


American Nurses Association. (2010). Nursing: Scope and standards of practice. (2nd ed.). Silver Spring, Maryland.

Institute of Medicine (IOM). (1994). American’s health in transition: Protecting and improving quality. Washington, DC: National Academy Press. Retrieved from: http://nationalacademies.org/hmd/reports/2010/the-future-of-nursing-leading-change-advancing-health.aspx

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Committee on Quality of Health Care in America. Washington, DC: National Academy Press. Retrieved from: http://nationalacademies.org/hmd/reports/1999/to-err-is-human-building-a-safer-health-system.aspx

Marquis, B. L. & Huston, C. J. (2017). Leadership roles and management functions in nursing: Theory and application. (9th ed.). Philadelphia: Lippincott Williams & Wilkins.

National Academies of Sciences. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

Roussel, L., Thomas, P., & Harris, J. (2016). Management and leadership for nurse administrators. (7th ed.). Burlington, MA: Jones & Bartlett Learning.

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