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AnalysisStrengthsWeaknessesOpportunitiesThreats
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Running head: IMPACT REPORT TO SENIOR LEADERSHIP 1
Copyright ©2017 Capella University. Copy and distribution of
this document are prohibited.
Impact Report to Senior Leadership
Learner’s Full Name
Capella University
Organizational and Systems Management for Quality Outcomes
May, 2017

IMPACT REPORT TO SENIOR LEADERSHIP 2
Nurse leaders play an important role in guiding nursing
professionals to achieve a health
care organization’s quality and safety standards—standards that
should help patients receive
high-quality care without negative outcomes on their health.
Despite efforts to maintain these
standards, health care organizations across the United States of
America have witnessed an
increase in the number of poor patient outcomes (that stem from
unsafe care. According to the
Quality Interagency Coordination Task Force, the consequences
of quality and safety issues in
patients have amounted to an annual loss of $29 billion (Huber,

2017).
The importance of maintaining patient safety standards in health
care will be explored
based on the challenges faced by a well-known nursing facility
in the United States of America.
Located in a major city, the facility provides 24-hour residential
care to the elderly and people
with special needs who require customized care. The facility
has been facing patient safety issues
connected to how its nursing professionals administer treatment
and monitor patients.
Patient Safety as a Nursing Challenge in the Nursing Facility
Nursing professionals are the primary caregivers in any health
care setting; they spend
the most time with patients as they administer treatment, detect
signs of deterioration in patients,
and build caring relationships with them. Therefore, safety
issues that cause any negative
outcomes in their patients can affect nursing professionals
emotionally and hinder their career
development (Lawton, Carruthers, Gardner, Wright, &
McEachan, 2012; Huber, 2017).
The nursing facility encountered safety issues caused by nurses
when administering

medicines, patients falling or injuring themselves because of
nursing negligence. These issues
Comment [A1]: Nice job identifying the
challenge of providing patient safety care
measures. Good inclusion of how unsafe
practices leads to emotional and decreased
career development in nurses as well as the
impact of sentinel events for the organization.
You stated that patients are negatively
impacted and could further explain what is
meant by that.
are called adverse events because they occur in clinical practice
and affect patients directly (U.S.
Food & Drug Administration, n.d.).
Following the perspectives of systems theory, which explain
how smaller parts of an
organization affect the whole, the safety issues caused by errors
in nursing practice can impact
the organization and its achievement of health care goals on a
larger scale. In fact, adverse events

in nursing may have multiple consequences across the entire
organization as different parts
interact symbiotically. For example, the safety issues have made
the facility vulnerable to
sentinel events, which are patient-related events that result in
death, permanent harm, or grievous
injury (The Joint Commission, 2017). Finding solutions to such
challenges in nursing practice
requires nurses to grow into genuine systems leaders who can
safeguard the goals of the
organization and nurture similar commitment in other nursing
professionals (Senge, Hamilton, &
Kania, 2015).
The Impact of Safety Issues on the Organization
Since its inception, the nursing facility has always prided itself
as a premier health care
organization that offers specialized physical, occupational, and
rehabilitative therapies, aside
from medical services to the elderly and people with special
needs. Through its mission, vision,
and core value statements, the facility has made a commitment
to improve people’s lives, abide
by health care ethics, adhere to local and national health care

standards, and provide affordable
services. The facility depends on skilled staff, nurses included,
to carry out the goals mentioned
in its mission, vision, and core value statements.
However, the adverse events taking place in the facility and
among its nursing
professionals are contradicting the mission, vision, and core
value statements.. Systems theory
Comment [A2]: Excellent point and nicely
Comment [A3]: Excellent work explaining
how unsafe practice issues conflict with the
organization’s mission and vision of improving
lives. Nice incorporation of systems theory.
Comment [A4]: Very true!
states that organizations have inherent weaknesses—latent
failures—that can cause adverse
events in patient care (Lawton et al., 2012; Huber, 2017).

Nurse leaders can ensure there is a culture of safety and quality
through implementation
of continuous quality improvement and safety management
initiatives. Organizational change
guided by systems theory plays a major role when introducing
any quality improvement and
safety management initiatives. An effective safety culture in
health care acknowledges change as
a common element in health care and can pre-emptively reduce
the probability of adverse events
(Huber, 2017). The culture of safety incorporates systems
thinking into patient-related decision-
making made by nurse leaders, which allows them and nursing
professionals to consider how
actions can affect an organization as a whole.
SWOT Analysis of Organizational Factors
The nursing facility had experienced a number of changes that
affected the nurses’ ability
to deliver safe care. The SWOT analysis helps the faci lity to
focus on the changes that have had
the greatest impact on health care quality and patient safety.

Comment [A5]:
Comment [A6]: Nice work identifying the
factors that impact the situation using a SWOT
analysis, such as budget cuts and the lack of
resources available to nursing leaders.
Table 1
SWOT Analysis of Organizational Factors
Strengths
for people with special needs
-of-the-art infrastructure and
technology

patients
Weaknesses
Budget cuts faced by the nursing
department
professionals
continuous quality improvement and safety
management initiatives
allocation of nursing professionals
across departments and gaps in staff
scheduling
teams
Opportunities

position to oversee patient safety and
quality care
Efforts to become a Magnet hospital
geriatric care and therapy for people with
special needs
competencies by national nursing
agencies
Threats
sources because of
federal budget cuts to health care programs
care organizations
Effective nursing leadership is crucial for the SWOT
opportunities to be translated into
actions that facilitate organizational change. Leaders are change
agents as they transform plans

into actions, motivate staff to align with the goals of the
organization, and communicate details
of the change process to all stakeholders. Comment [A7]: Lots
of great information
here. Nicely written and well organized.
Defining the New Leadership Position at the Nursing Facility
The new leadership position that will be created is the chief
nursing officer (CNO). The
CNO will be responsible for planning, executing, and evaluating
the strategies to improve safety
issues. The CNO will also be a part of the facility’s shared
governance council and will head a
team that will analyze the organization for latent failures.
Certain key competencies—
knowledge, skills, and attitudes—will define the broad nature of
the CNO’s role and influence in
the organization.
Key Competencies for the Nursing Leadership Position

The American Organization of Nurse Executives (AONE, 2015)
details five professional
leadership competencies that can help the chief nursing officer.
The five competencies are
communication and relationship-building, professionalism,
leadership skills, business skills, and
knowledge of the health care environment (AONE, 2015).
By developing these competencies, the CNO will gain (a)
knowledge about global trends
in nursing and health care; (b) expert problem-solving and
critical-thinking skills for making
decisions; (c) an understanding of patient safety and quality
care; (d) an understanding of
organizational politics, authority, and power dynamics; (e)
relationship-building and team-
building skills; (f) knowledge of systems theory and systems
thinking; and (g) the trust of health
care professionals in the organization and the skills to adapt to
organizational change.
Influence of Leadership Power in Patient Outcomes
Demonstrating appropriate power and authority is a prerequisite
for productive nursing
leadership. Having this authority allows nurse leaders to recruit

and retain a highly skilled
nursing workforce, which is a critical indicator of patient
safety. They can also maintain the
Comment [A8]: Good identification of the
skills required of a nursing leader which
should consist of knowledge, leadership skills,
and attitude. Nice explanation of how the
nurse leader should approach change to allow
for success by understanding systems theory
and the organization’s dynamics as this will
provide the nurse leader with the power to
implement the change effectively.
Comment [A9]: Great assessment of how
the nurse leader position will have the power
to positively impact patient outcomes and
stabilize the organization financially.
productivity of nursing professionals by allocating training
resources without management
interference. These empowered roles help stabilize an
organization's financial performance,
thereby impacting the delivery of cost-effective and quality care

to patients (Australian College
of Nursing, 2015).
Conclusion
Successful health care organizations are those that understand
the role of nursing
professionals in patient outcomes and involve the workforce in
addressing safety and quality
concerns. Such organizations demonstrate effective management
that identifies latent
organizational factors behind adverse events and implements
solutions accordingly. Nurse
leaders are crucial to this system as they communicate
organizational and nursing goals to other
health care professionals in the organization. Acknowledging
these nursing roles and
incorporating them into an organization's strategic planning
help health care professionals adapt
to sudden environmental changes that affect safety and quality
(Salmela, Eriksson, &
Fagerström, 2013).

Comment [A10]: Great job!
Comment [A11]: Very nice summary of
what was discussed in the paper.
References
American Organization of Nurse Executives. (2015). AONE
Nurse Executive Competencies.
Retrieved from http://aone.org/resources/nec.pdf
Australian College of Nursing. (2015). Nurse leadership [White
paper]. Canberra: American
College of Nursing. Retrieved from
https://acn.edu.au/sites/default/files/leadership/ACN_Nurse_Lea
dership_White_Paper_FI
NAL.pdf
Huber, D. L. (2017). Leadership and nursing care management
(6th ed.). Philadelphia: W. B.

Saunders. http://dx.doi.org/10.7748/nm.21.6.13.s14
Lawton, R., Carruthers, S., Gardner, P., Wright, J., &
McEachan, R. R. C. (2012). Identifying the
latent failures underpinning medication administration errors:
An exploratory
study. Health Services Research, 47(4), 1437–1459.
http://dx.doi.org/10.1111/j.1475-
6773.2012.01390.x
Salmela, S., Eriksson, K., & Fagerström, L. (2013). Nurse
leaders’ perceptions of an approaching
organizational change. Qualitative Health Research, 23(5), 689–
99.
http://dx.doi.org/10.1177/1049732313481501
Senge, P., Hamilton, H., & Kania, J. (2015). The dawn of
system leadership. Stanford Social
Innovation Review, 13, 27–33. Retrieved from
https://ssir.org/articles/entry/the_dawn_of_system_leadership#
The Joint Commission. (2017). Sentinel event policy and
procedures. Retrieved from https://
jointcommission.org/sentinel_event_policy_and_procedures/

U. S. Food & Drug Administration. (n.d.). What is a serious
adverse event? Retrieved from
https:// fda.gov/safety/medwatch/howtoreport/ucm053087.htm
Comment [A12]: APA references looks
great!

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