Research a case study involving a patient situation in which there was an adverse event or a near miss. The case study should have the following details:

  1. A patient related situation exists that needs improvement.
  2. There is a chain of events leading to a decrease in quality of care.
  3. The situation is interdisciplinary and relies on a team approach for improvement.

Based on this case study, you will complete an in-depth case analysis that includes:

  1. Create process map of the current state to describe the occurrence, as well as an ideal process map.
  2. Analyze your patient case using root cause analysis and develop a plan of improvement utilizing the quality improvement model, Plan, Do, Study, Act.
  3. Describe the changes and test plan that are created, as well as the challenges of becoming a “change agent”.
  4. Discuss the leadership model that you will use to help you succeed.

Write a paper with the above information. The paper will be in APA format and no more than 5 pages, not including title and reference pages. This assignment is due at the end of Unit 4 and is worth 10% of your final grade.

Use the following outline to assist you with case analysis:

  1. Overall Process Map:
    • For the patient in this case study, draw a picture or a diagram of the overall care process. Flowcharts and stick figures can be used in the process map.
    • Show the major steps in the story.
  1. What contributed to this adverse event?
    • From the overall care process map, create a list of things that went wrong in the care of the patient.
    • Group these problems and errors into sensible categories. Examples include “communication breakdown” and “equipment failure.”
    • Use the “ask why five times” method and/or a fish bone diagram to organize your thinking.
  1. The Ideal Process Map
    • Draw a picture or a diagram of the ideal overall care process for the patient. Use diagrams or a process map here rather than text.
  1. Find an evidence-based practice guideline related to your topic.
  • What does the guideline state about your topic?
  • How can the guideline be used to improve the patient’s care?
  1. Process Improvement
    • Identify at least one process in the case that, if improved, could have moved the patient’s care closer to the ideal.
    • For the process you identified, create an aim statement for improvement.
      • A good aim statement specifies “how good, by when, for whom.”
      • The aim statement you create will be your process improvement measure.
  1. How would you know the changes made a difference?
    • Suggest at least two measures that could be used to
      • Track the progress of your improvement effort (process measures)
      • Assess the impact of improvement on the targeted population (outcome measures)
      • Monitor the costs associated with improvement (balancing measures)
  1.  What changes will you make?
    • What changes in the current system of care would you recommend testing? (i.e., are there small-scale, incremental changes that would be beneficial? Are there new care processes that need to be designed and implemented?)
  1.  Plan Your Tests
  • Provide a plan to test the changes you have proposed.
    • What questions do you hope to answer with this test, and what do you predict the answers are?
    • What changes will be tested?
    • How will the changes be tested (consider small scale early)?
    • Who will run the test?
    • Where and when will the test take place?
    • What information is important to collect?
    • Why is it important? Who will collect the data?
    • Who will analyze the data prior to study?
    • Where will data be kept?
    • When will the collection of data take place?
    • How will the data be collected?
  1.  Write out all the steps of your Plan, Do, Study, Act quality measure.
    • Include a specific aim statement that describes your process measure
    • Define your numerator and denominator for your measure
    • Describe your tests, as listed above in number 7
    • Analyze the data you might see if there was not an improvement
    • Plan the actions you would take to improve the process
  1.  What challenges might leadership face?


  • What is a “Change Agent” and what are the challenges associated with making changes in an organization?
  • What Leadership Model will you use to help achieve the changes?
  1. Follow the rubric below and the assignment instructions.
Criteria Level of Achievement

Points Possible

Process Map and Ideal Process Map

Weight 15%

100.00 %

Presentation contains excellent pictures and /or diagrams /Flowcharts showing the major steps in each of the overall care processes and of the ideal care process.

Root Causes

Weight 20%

100.00 %

Presents an excellent categorization and listing of problems and errors that occurred in this case. There is evidence that the “ask why five times” method and/or fishbone diagram was used to organize this section of the presentation.

Evidence Based Practice

Weight 15%

100.00 %

Discusses the Evidence Based Practice guideline and the implications for improvement in the patient case. Includes at least two guidelines from scholarly sources.

Improving Part of the System and Measures

Weight 10%

100.00 %

Describes more than one process that could have moved the care process closer to ideal. Includes well developed aim statement for each process identified.

Plan, Do, Study, Act

Weight 10%


Identifies all the elements of the performance improvement measure including the aim statement, the numerator and denominator that is collected and analyzed, and the actions taken to improve the measure, and the reevaluation of the data. Describes a specific plan in detail that will test and evaluate the proposed changes.

Leadership Challenges and Solutions

Weight 15%

100.00 %

Provides an excellent description of the obstacles that the organization’s leaders must overcome to implement the proposed plan.

APA Format

Weight 5%


Correct APA, no grammar or spelling error


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