N 774

The Final Paper

The Scenario

Island Community Hospital is a new, 60 bed, not-for-profit, adult medical-surgical hospital

located on the island of Mokulele, Hawaii. The island population is approximately 56,000 and
the main industries are coffee and tourism. The hospital provides level I medical-surgical care to
its adult residents and transports other cases to Oahu. Services provided include: emergency
room, medical-surgical inpatient, outpatient surgery, skilled nursing, respiratory therapy, dietary,
diagnostic imaging and laboratory services.

The hospital senior leadership is composed of a CEO, CFO, medical director, HR director, and a
CNO. The Medical Executive Committee has 5 members and the Board of Directors has 7
members. The hospital employs 75 RNs and 15 certified nurse aides as well as ancillary services
staff in respiratory, dietary, imaging and lab. All employees were hired in the past six (6)
months. 29 physicians have hospital privileges. The hospital was licensed by the State of Hawaii
in June 2018 and Medicare certified by CMS in July 2018.

Mission “To provide the best health care by the best practitioners to the residents of the
community so they can live healthy and productive lives.”

Vision “By 2021, Island Community Hospital will be the best small hospital in Hawaii”

Strategic Goals

1. Earn Joint Commission accreditation within 5 years

2. Achieve at least the Hawaii State average performance results for:
 CMS clinical care process and outcome measures
 Overall rating of the hospital on the Patient Experience Survey
 Medicare cost per patient day
3. Maintain an overall budget variance of < 3%
4. Attain an employee turnover rate of < 8%.
 N 774
The Final Paper

The Assignment - Putting It All Together (Turn in via the drop box. Due date: 12/6/2018

Imagine you are the newly hired CNS for the hospital. Your primary responsibilities are to (1)
educate and mentor nursing staff in providing evidence-based, high quality, safe care; (2) to lead
the organization in meeting state and national goals related to safety and quality; and (3) to lead
changes in the organization that facilitate quality improvement, patient safety and lower health
care costs.

During the interview, you learned that physicians and staff are trying hard to achieve good
outcomes and are excited you have been hired to lead the quality and patient safety program.
Both the BOD and the CEO/CFO/CNO executive leaders have pledged their support. You are
hired and begin work in 2 weeks.

The organizational priority is to create a culture of quality and patient safety. Since you will lead
the effort, think about how you plan to create a culture of quality and patient safety in the new
hospital. Consider:

 What are the key elements needed to “create and maintain a culture of safety and quality
throughout the organization?”
 What are the characteristics of a high quality, safe organizational culture?
 Who are the key players? What are their roles?
 Describe some of the strategies you will use to achieve the elements.
 What is your rationale for selecting the elements and the corresponding strategies?
 What will be your priorities in the first few months? Why are they priorities?

Grading:

 Written assignments are to be in Microsoft Office-Word format, single spaced, using 1”

margins and no smaller than an 11-point font.
 Formatting for the citations in the assignment must follow a consistent formatting style.
You may choose the format.
 Writing is expected to meet professional standards regarding grammar, punctuation and
clarity and should reflect concise thinking and reasoning.
 Grading is based on meeting the criteria (see grading rubric) and is at the discretion of the
faculty.
 Students are expected to submit to the course faculty by midnight of the due date via the
Drop Box tool in Laulima. Assignments will NOT be accepted via UH email or other
means. Late assignments will impact the final grade.