The purpose of this assignment is to examine factors that contribute to a just culture and a culture of safety and how they are implemented within a health care organization. Identify a health care organization that uses a just culture and culture of safety. Research how a just culture and culture of safety are implemented within that organization.

In a 1,000-1,250 word paper, analyze the factors that create a just culture and culture of safety within your selected organization. Include the following in your paper:

A description of the health care organization you selected.
An analysis of the factors that create a just culture and culture of safety within the selected health care organization.
An evaluation of how the mission and vision of your identified organization align with the factors that create a just culture and culture of safety, including two or three examples.
This assignment requires a minimum of two scholarly sources. If the necessary information is not readily available on the organization’s website, you may need to set up an interview with someone at the organization.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite Technical Support Articles is located in Course Materials if you need assistance.  Safety in a Healthcare Organization Essay Paper

A Just Culture and Culture of Safety in a Healthcare Organization
A just culture is a culture of safety that concentrates on continuous learning from quality improvement situations with the goal of improving patient safety. It fosters improved recognition of situations that threaten patient safety and enables staff to learn from these situations. The staff are empowered to act and to exercise evidence-based practice in pre-empting subsequent instances that threaten patient safety. The purpose of this paper is to look at the factors associated with a just culture and a culture of safety within the healthcare organization chosen.
The Healthcare Organization Chosen
The organization selected is a healthcare organization in the form of a mid-level hospital in a metropolitan area with a dense population. It offers primary, secondary, and tertiary services. These include some specialty services too such as reproductive health services, pediatrics, and orthopedics. The organization has culture of implementing changes from time to time and has within its policies that clinicians and nurses have to use the latest interventions that have scholarly evidence backing them for efficacy. In other words, the organizational culture in the hospital is that of evidence-based practice (EBP) at all times (Melnyk & Fineout-Overholt, 2019; Crabtree et al., 2016). The staff at the hospital are always encouraged to question common practice and to carry out clinical inquiry at all times when the opportunity presents itself. This is because the hospital policy is that of commitment towards realization of the best patient outcomes at all times.
This is an organization that is favorably rated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) on matters patient safety. It has a good patient safety record and has not recorded any sentinel event within a span of three years. This is why it recently received the Gold Standard Certification for care quality and patient safety from the JCAHO. In the hospital there is a quality improvement (QI) committee that meets every week to review the events f the week and any reported cases of breach of quality within the organization. All departments are represented in the committee as well as management. In the event that any QI issues are noted, immediate remedial action is taken in the form of QI initiatives that are unformed by evidence-based practice or EBP. Most of the time, the guidelines and protocols used to correct these QI situations are standard and scientific and are from the Agency for Healthcare Research and Quality (AHRQ). The AHRQ is another regulatory body concerned with quality improvement in healthcare settings just like the JCAHO.

The Quadruple Aim
This organization has been successful on matters quality improvement because it long embraced the concepts and goals of the Quadruple Aim (Feeley, 2017). The institute for Healthcare Improvement (IHI) is the body that first suggested the concept of triple aim with three major objectives or goals. This was later expanded to Quadruple Aim with four goals. The first three goals that were in the triple aim are improvement of the health of populations, making patent experiences better, and reducing the cost of healthcare (Feeley, 2017). However, it is the fourth objective that transformed the triple aim into the Quadruple Aim that s more significant in the case of this organization. That fourth objective is the creation of a conducive working environment for the healthcare workers so that they can deliver (Sikka et al., 2015). The organization management had realized very early that the quality of care is multifactorial in nature. That means that it is influenced by many factors. It is these factors that create a just culture and culture of safety within this organization. These are the factors that are discussed below.
The Factors Creating a Just Culture and Culture of Safety within the Chosen Organization
These factors are related to the provision of care that is safe, effective, efficient, patient-centered, timely, and equitable (Tzelepis et al., 2015). In other words, the factors create an environment in which quality care can be provided and exceptional patient outcomes realized by all. The factors are as follows:
1. Transformational leadership
2. A welcoming and safe working environment for employees
3. The use of technology to prevent and reduce medication errors
4. Care coordination through membership of an Accountable Care Organization or ACO  Safety in a Healthcare Organization Essay Paper

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Transformational Leadership
The first factor that is related to a culture of safety and a just culture within the above organization is the presence of transformational leaders at all the levels of management (Choi et al., 2016). But what has especially facilitated quality care is the presence of transformational nurse leaders in all the departments of the hospital. This did not happen by chance but by design. It was a policy that the organization’s top leadership decided to adopt several years ago after extensive clinical inquiry and evidence-based research. Transformational nurse leaders with a track record of excellence and exceptional relationships with subordinates were then recruited for all the departments. The results were immediate. Whereas initially there were many cases of quality lapses in care, now there were les and lees cases of the same. Within a year, readmission rates, patient fall rates, the rates of hospital-acquired infections (HAIs), the rates of catheter-associated urinary tract infections (CAUTI), the rates of pressure ulcers, and the rates of central line-associated blood stream infections (CLABSI) all reduced substantially. Others became non-existent completely, such as pressure ulcers. All these outcomes were attributable directly to the empowerment of the nurses by the transformational nurse leaders and the creation of a welcoming and friendly workplace environment.
A Safe Working Environment
Psychological safety is the state of having an environment that does not induce anxiety and stress. In a healthcare workplace environment in which there is intimidation, victimization, and unending conflicts there will always be instances of breaches of quality. This is because the nurses working there will have no psychological safety. Studies have shown that a nurse who is stressed and anxious is prone to committing errors that put the patient’s life at risk. These include medication errors. In the above organization, this has been avoided by having transformational nurse leaders manage units and lead the nursing workforce.

The Use of Technology to Prevent Medication Errors
Very early on the QI committee at the healthcare facility in question had realized that medication errors were the most reported QI issue within the organization. After a well-informed and targeted clinical inquiry, recommendations were made to upgrade the electronic health record (EHR) system to include newer innovative applications for drug administration. These eliminated most of the human-human interfaces and replaced them with human-technology-human interfaces. The technology in-between then served as the buffer preventing the occurrence of medication errors. Some of these applications were Automated Medication Dispensing Cabinets (ADCs), Computerized Provider Order Entry (CPOE), Bar Code Medication Administration (BCMA), and Patient Data Management Systems (PDMS) amongst others (Alotaibi & Federico, 2017).
Care coordination through membership of an Accountable Care Organization or ACO
In the US, care fragmentation has been recognized as one of the leading causes of poor quality care and the occurrence of poor patent outcomes within the healthcare system. It involves having no coordination of care such that a patient has to repeat procedures when they visit different providers. What is even more unacceptable is that with care fragmentation, the patient runs the risk of getting duplicate prescriptions placing their lives in danger from overdose and adverse drug reactions. This organization avoided this scenario by becoming part of an existing Accountable Care Organization. This is a group of providers that provide affordable care to patients and share their information and data freely within the confines of confidentiality. This way, care fragmentation is avoided as referrals are made amongst member providers.
Evaluation of the Mission and Vision
The mission of the organization is to provide the safest possible level of care to the population and improve the healthcare status of the population. Its vision is to be the leading care provider with the best safety record in the whole state. This mission and vision accurately align with the factors discussed above that create a just and safe patient care environment. Two examples are that transformational leadership begets patient safety; and improving the care of populations is all about care coordination.
Conclusion
Patient safety is a very important element in healthcare provision. It is crucial for healthcare organizations to identify the factors that create a just and safe environment for the provision of the safest levels of patient care. This paper discussed one such organization and the factors in it assuring safe patient care.

References
Alotaibi, Y., & Federico, F. (2017). The impact of health information technology on patient safety. Saudi Medical Journal, 38(12), 1173–1180. https://doi.org/10.15537/smj.2017.12.20631
Choi, S.L., Goh, C.F., Adam, M.B.H., & Tan, O.K. (2016). Transformational leadership, empowerment, and job satisfaction: The mediating role of employee empowerment. Human Resources for Health, 14(1), 73. https://doi.org/10.1186/s12960-016-0171-2
Crabtree, E., Brennan, E., Davis, A., & Coyle, A. (2016). Improving patient care through nursing engagement in evidence-based practice. Worldviews on Evidence-Based Nursing, 13(2), 172–175. https://doi.org/10.1111/wvn.12126
Feeley, D. (2017, November 28). The triple aim or the quadruple aim? Four points to help set your strategy. Institute for Healthcare Improvement. http://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategy
Melnyk, B.M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice, 4th ed. Wolters Kluwer.
Sikka, R., Morath, J.M., & Leape, L. (2015). The Quadruple Aim: Care, health, cost and meaning in work. BMJ Quality & Safety, 24(10), 608-610. http://dx.doi.org/10.1136/bmjqs-2015-004160
Tzelepis, F., Sanson-Fisher, R., Zucca, A., & Fradgley, E. (2015). Measuring the quality of patient-centered care: Why patient-reported measures are critical to reliable assessment. Patient Preference and Adherence, 9, 831-835. https://doi.org/10.2147/ppa.s81975

Safety in a Healthcare Organization Essay Paper