[ANSWERED 2022] You have been chosen by your healthcare organization to investigate and recommend a major healthcare system initiative. This initiative should support and drive excellence in

Last Updated on September 26, 2022 by Admin

Week 7: Assignment – Signature Assignment: Healthcare Initiative Paper

Assignment Prompt

You have been chosen by your healthcare organization to investigate and recommend a major healthcare system initiative. This initiative should support and drive excellence in patient care, directly or indirectly. Your objective is to provide the leadership team with a comprehensive overview of the initiative you choose that is supported with research and data.

Prepare a formal review/overview of a Healthcare System Initiative that directly or indirectly drives excellence in patient care. Examples include but are not limited to:

  • ANCC Magnet Journey
  • Trauma Center Verification
  • ANCC Pathway to Excellence
  • Certification for Primary Stroke Center
  • Primary Care Medical Home Certification
  • New BSN Graduate Nurse Residency Program

The paper will include (but is not limited to) the following:

  • An introduction that identifies and explores the significance of the initiative, a body with sections separated using Level 1 and Level 2 APA headings, and finally, a concise conclusion that highlights the key elements of the initiative;
  • Review of the literature associated with the specific initiative;
  • Recommended leadership theory/style;
  • Recommended communication strategies (internal and external);
  • Recommended change management/theories, strategies and support needed from the organization;
  • Anticipated conflict management/resolution strategies;
  • Other implications: Potential costs, anticipated benefits and available marketing support.

Submit the final paper to the D2L Brightspace assignment upload page.

A Note on Citation of Appendix or Appendices and Figures

A single Appendix is titled “Appendix” centered on a separate page and followed by the figure on the next page.  Follow APA formatting for Appendix or Appendices, p. 39, APA 7th ed. manual.  In-text, refer the reader to the Appendix for one diagram/figure, ie, (Refer to Appendix A, p. x); for multiple figures use (Refer to Appendices A and B, pp. x and x).  Type Figure 1 with title and caption below figure. Refer to example in APA manual, p. 53, and explanation of legend and caption for figures on p. 158, 5.23, pp. 159-161.


  • Due: Monday at  Midnight
  • Length: 8-10 pages, excluding the title and reference pages
  • Research: A minimum of 10 scholarly, peer-reviewed reference citations are required as well as appendices for tables and/or graphs labeled using APA 7th ed format.
  • Format: APA 7th ed.

See USU Writing Assignment Rubric for additional details and point weighting.

Expert Answer and Explanation

Implementation of Healthcare System Initiative

The specialty hospitals such as the trauma center specialize in the management of specific patient needs. For example, the trauma center focuses on delivering health care services to people with injuries including victims of accidents. Like any other hospital, a trauma center is subject to the regulations and standards that dictate the procedures involved in care delivery, and a healthcare organization that specializes in this area, therefore, should commit to comply with these standards. To ensure compliance, the organization invites a team of experts to assess the organization’s services against the established standards, pinpointing flaws and strengths. This process is significance in the sense that it helps optimize the quality of health services for the trauma patients. The success of the Trauma Center Verification (TCV), as the process is popularly known, depends on numerous factors including leadership style, communication strategies, and the change management theories used as described in this paper.

Problem Statement

Although providers of medical services are required to meet certain quality and safety standards, cases of medical malpractice are still common, and they largely stem from noncompliance to the protocol for care delivery. In 2013, for example, a patient at Cony Island Hospital lost his life following the blood transfusion error caused by the wrong identification of the patient’s blood type (Oginski, n.d.). This is one of the many incidences which happen when hospitals fail to comply with the laid down standards, and some of these events may cause an increase in the medical expenses. Some of the negative outcomes associated with malpractice stem from the lack of verification of the trauma center. Due to the lack of verification, these centers may not be in a position to gauge whether they are doing certain things right, and this may potentially expose the organization to the risk of mistakes. To cushion itself against these problems, a trauma center should undergo a verification process.

Review of Literature Related to the Initiative

A number of literature sources explore the subject of the TCV in terms of purpose, effectiveness and benefits. El-Menyar and colleagues (2020), for example, examine whether accrediting the organization can translate to better clinical outcomes, and their results confirm a hypothesis that TVC can bring positive impact to the hospital, and to the patients by reducing hospitalization. However, not everyone see verification as a solution to the clinical issues such as poor quality of treatment because some studies have yielded results that contradict El-Menyar et al. (2020). Botomen et al. (2021) found that verification does not guarantee a hospital success in terms of the outcomes of the patient care.  Botomen et al. (2021), however, used only 20 subjects for their study, and their results may not be valid.  If one were to consider the validity of the studies to make decisions, therefore, El-Menyar et al. (2020) would be ideal evidence source.

The approaches used in the TCV largely determine the outcomes of the TVC, and a hospital should take this into account when thinking of undergoing a verification process. External verification is one of the approaches used to verify the trauma center. While this method eliminates bias by comparing the hospital’s processes against the external standards, it may not bring tangible benefits in terms of improving compliance with the standards. This is seen in Flodgren et al. (2016) in which they determined that certification did not necessarily lead to compliance with the standards. These findings are crucial to guiding the decision-making when it comes to choosing whether to perform the TCV.

Although some studies discredit verification as a solution to certain quality issues, some experts see it as an approach to making health care safer. Fleshman and Newton (2021) recognize the positive impact brought by facility verification. They point out that the process contributed to successful response to the COVID-19 when the pandemic broke out. These findings can be replicated to the trauma center.

Recommended Leadership Theory or Style

Leadership is critical to the success of the healthcare system initiative, and a leader can exert influence to the TCV by using transformational theory. The theory emphasizes improving the engagement and motivation of employees, and empowering them to be able to perform certain tasks on their own. Another quality of the theory is that it is consist of four components including the intellectual simulation component. This particular element of the theory recognizes the leader’s role in collaborating with and supporting employees to find solutions and become independent thinkers. Idealized influence is the other component, and it involves displaying positive character and demonstrating high level of integrity. The goal is to have followers emulate the leader (Steinmann, Klug, & Maier, 2018). Conversely, inspiration motivation involves articulating the message that appeals to followers to motivate them. The leader also attends to the needs of every of their follower, and this is emphasized by the component, individualized consideration.

The transformational theory, given its components and emphasis, can help improve the results of the TCV. For the leader to mobilize employees and involve them in the implementation of the proposed healthcare system program, they need to feel employees feel confident. They can achieve this by motivating their followers, and articulating what the organization wants to achieve by verifying the center. Running a success TCV can be a challenge especially if employees have inadequate creative skills. A leader can overcome these challenges by soliciting ideas from their juniors, challenging assumptions, and influencing the followers’ way of thinking. When employees have these skills, the leader can work with them to determine best approaches that can support verification (Choi et al., 2016). Because employees’ support is necessary for the verification to go on according to the plan, it is important for the leader to reach out to everyone to find a way they can support the initiative.

Recommended Communication Strategies (Internal and External)

Lack of effective internal communication processes can cause the delay in the verification of the center because it may cause misalignment of expectations and goals, and to respond to this problem, the hospital needs to have strategies for internal communication. Planning the communication including the method of conveying the message and the specific message to send, for example, can help the leader better share the message to reach the target audience. Selecting the right tool for communication, still, is an important strategy. Email is an ideal method because it allows everyone to receive instant messages. To ensure internal communication becomes successful, the organization’s leadership will need to make communication fun by having workers talk about past funny encounter, and link the conversation to TCV. This can be useful in an open meeting environment where members openly share their ideas. The person spearheading the initiative should also consider establishing the feedback channels so that everyone will have the opportunity to give feedback (Bell & Condren, 2016).

Apart from the employees, there are other parties outside the organization who will participate in the implementation of the TCV, and communicating with this group is crucial to successful implementation. To ensure that the audience relates with the message, the communications team should first determine the characteristics of the audience including what they may want to hear. For example, patients may want to know the measures the hospital has in place to address issues such as delayed treatment. The other strategy is to choose the right channel for conveying the message. Professional journals, for example, can help support the delivery of the organization’s message to the external stakeholders. The website is the other platforms which the HCO can utilize to share information on what is working on as far as TCV is concerned. Furthermore, the entity can leverage the social media by creating and promoting posts containing the message it wants to deliver (Bell & Condren, 2016).

Recommended Change Management Theories, Strategies and Support Need from the Organization

Change management can be a challenge especially if employees resist the change, and to ensure everyone reads from the same page, an organization can use Lewin’s change theory. The theorist used an analogy of melting of ice to explain how change occurs, and according to the theory, change begins with unfreezing, goes into the transition phase, and then it freezes. Prior to initiating change, one would expect employees to have a mindset in which they believe the change cannot happen. Unfreezing seeks to address this particular problem, and it involves sensitizing the employees about the reason why change is critical. In the second phase, those leading the change come up with the plan, deploy communication tools, and encourage everyone to take part in the change. This is the stage when the organization transitions from unfreeze to the freeze stage (Harrison et al., 2021).  Finally, employees embrace the change and see it as a normal process within their organization.

Lewin’s model can guide the change process involved in the verification of the TCV. The first step of the change will involve surveying the stakeholders’ views regarding the change to establish what the organization should change. This is also the stage in which the organization creates a message that explains the reason why change is necessary, and it can use the social media and other platforms to achieve this goal. The change phase is where the leadership’s role and information flow become more prominent. At this point, the leader defines the vision, and they motivate their followers to support the change. To ensure that things run smoothly, the leader lets information to flow freely so that everyone works in a coordinated fashion to facilitate the verification of the facility. The leader also empowers the employees so that they acquire skills that can help them adapt to the change. The process finalizes with incorporating the new changes into the organization’s culture so that everyone sees it as a normal process (Harrison et al., 2021).

The change model alone cannot guarantee a successful change process, and to improve the chances of running a successful healthcare system initiative, a hospital needs to combine the model with certain strategies. For example, careful planning is needed, and the plan should define what the organization seeks to achieve, and the scope of the TCV. Creating a plan is the first step involved in understanding the nature of the problem and the resources that can support the change. When communicating the reason for carrying out the verification, one has to be as clear as possible to build trust with everyone. To attract the employees’ support throughout the different stages of change, a leader should be consistent in terms of how they communicate with the employees (Harrison et al., 2021). Doing this can help address any doubt or negative attitudes that might hamper their support for the initiative. Furthermore, focusing on skill-development by offering coaching and education opportunities can help employees prepare for the change.

Anticipated Conflict Management/Resolution Strategies

Conflicts can have negative effect on the progress of the initiative, and some of the sources of conflicts may include the clash of ideas, and the lack of a clear definition of the roles of those involved in implementation of the initiative. For example, a manager may want employees to use an approach that involves the use of evidence to guide the verification process. Conversely, employees may want to perform the verification by following a certain approach which they feel is easy to use. This class of views regarding how things should be done can make employee lose morale especially if the leader coerces them to use the method (Lewitter, Bourne, & Attwood, 2019).

The Trauma Center should employ certain strategies to address the conflicts in case the conflicts occur. Coaching workers on how to manage differences is one of the strategies the hospital can use to prevent future problems. The organization’s leadership can also reduce the risks of occurrence of conflicts by encouraging members to collaborate, and coordinate decision-making. Additionally, the facility can create and cultivate a culture in which workers align their behaviors with the ethos of the hospital. By using this particular strategy, the organization will instill desirable behaviors in employees, and they will avoid conflicts instead of engaging in confrontations (Lewitter et al., 2019).

Other Implications of the Initiative including Potential Costs, Anticipated benefits and Available Marketing Support

The initiative will bring other benefits related to the costs and availability of the market. There is likelihood that the initiative will improve the quality and safety of care because the hospital will strengthen its internal processes, if the TVC succeeds in revealing the flaws in the internal operations. Improved compliance will translate to fewer cases of medical mistakes, and the costs of treating patients will reduce. With the decline in cases of medical errors at the hospital, the image of the trauma center will improve, and people with injuries will prefer to receive treatment at the hospital.


In conclusion, among the benefits the TCV will bring include fewer cases of clinical quality issues, and lawsuits related to malpractice. If the organization wants to succeed in carrying out a succeed TCV initiative, it needs to employ leadership and change theories to guide and direct the change process. The transformational theory fits into the healthcare initiative because it inspires and motivates employees to embrace change. The theoretical framework also prepares employees to develop skills and knowledge that they can use to improve the outcomes of the initiative.


Batomen, B., Moore, L., Carabali, M., Tardif, P. A., Champion, H., & Nandi, A. (2021). Effectiveness of trauma centre verification: a systematic review and meta-analysis. Canadian journal of surgery. Journal canadien de chirurgie64(1), E25–E38. https://doi.org/10.1503/cjs.016219.

Bell, J., & Condren, M. (2016). Communication Strategies for Empowering and Protecting Children. The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG21(2), 176–184. https://doi.org/10.5863/1551-6776-21.2.176.

Choi, S. L., Goh, C. F., Adam, M. B., & Tan, O. K. (2016). Transformational leadership, empowerment, and job satisfaction: the mediating role of employee empowerment. Human resources for health14(1), 73. https://doi.org/10.1186/s12960-016-0171-2.

El-Menyar, A., Mekkodathil, A., Asim, M., Consunji, R., Strandvik, G., Peralta R….& Al-Thani, H. (2020). Maturation process and international accreditation of trauma system in a rapidly developing country. PLoS ONE, 15(12). Doi: https://doi.org/10.1371/journal.pone.0243658.

Fleshman, J., & Newton, S. (2021). Quality Verification Enhanced a Tertiary Care Hospital’s Response to COVID-19. Journal of the American College of Surgeons233(2), 311–313. https://doi.org/10.1016/j.jamcollsurg.2021.04.007.

Flodgren, G., Gonçalves-Bradley, D. C., & Pomey, M. P. (2016). External inspection of compliance with standards for improved healthcare outcomes. The Cochrane database of systematic reviews12(12), CD008992. https://doi.org/10.1002/14651858.CD008992.pub3.

Harrison, R., Fischer, S., Walpola, R. L., Chauhan, A., Babalola, T., Mears, S., & Le-Dao, H. (2021). Where Do Models for Change Management, Improvement and Implementation Meet? A Systematic Review of the Applications of Change Management Models in Healthcare. Journal of healthcare leadership13, 85–108. https://doi.org/10.2147/JHL.S289176.

Lewitter, F., Bourne, P. E., & Attwood, T. K. (2019). Ten Simple Rules for avoiding and resolving conflicts with your colleagues. PLoS computational biology15(1), e1006708. https://doi.org/10.1371/journal.pcbi.1006708.

Moon, S. E., Van Dam, P. J., & Kitsos, A. (2019). Measuring Transformational Leadership in Establishing Nursing Care Excellence. Healthcare (Basel, Switzerland)7(4), 132. https://doi.org/10.3390/healthcare7040132.

Oginski, G. (n.d.). Man dies at Coney island Hospital after Blood Transfusion Error. https://www.oginski-law.com/blog/man-dies-at-coney-island-hospital-after-blood-transfusion-error.cfm.

Steinmann, B., Klug, H., & Maier, G. W. (2018). The Path Is the Goal: How Transformational Leaders Enhance Followers’ Job Attitudes and Proactive Behavior. Frontiers in psychology9, 2338. https://doi.org/10.3389/fpsyg.2018.02338.

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