Running head: THE QUALITY IMPROVEMENT APPLICATION

The Quality Improvement Application

Anthony Failano Gomez, PT, RN, BSN, MSN, LSS, LEU, DNPs, CPHQ
Walden University
Organizational and Systems Leadership for Quality Improvement
May15, 2013

THE QUALITY IMPROVEMENT APPLICATION

The Quality Improvement Application

In the current status of the healthcare industry where consumers are fully aware of the
services they should receive and with the advent of technology which makes these services
accessible, continuous quality improvement of services and patient care is important to meet
desired patient outcomes and care-recipient satisfaction. Brown (2011) defined Quality
Improvement as an approach focused on improving defective processes to improve the quality
of the outputs (p. 8) that aims to provide high-quality services which is done to the utmost
precision every time services are delivered.
Quality improvement is a major part in the quality management process developed by Mr.
Joseph M. Juran termed as the Juran Trilogy. This trilogy provides a logical way for the
understanding the whole process of Quality Management, which includes Quality Planning and
Quality Control. Brown (2010) empathized that Quality Improvement is used to determine
causes of process failure or inefficiency, utilization of combined efforts of a team to study and
progress existing processes in an organization, and for the advancement of process performance
to be able to achieve desired goals.
Quality management and improvement has been a driving a force in healthcare industry
ensuring patient safety and satisfaction. Quality management and improvement is a very tedious
process that requires certain factors, external and internal, which directly affects the healthcare
professionals effort. As Brown (2010) stated there is increased emphasis placed on improving,
in a prioritized approach, all the interrelated processes and services that impact the quality of
care and affect patient outcomes: governance, managerial, and support activities, as well as
clinical activities (p.18).

THE QUALITY IMPROVEMENT APPLICATION

Needlestick Injury
The Centers for Disease Control and Prevention (CDC) (2013) indicated that there are an
estimated 385,000 percutaneous injuries, citing needlesticks as one, occurring in hospitals every
year. These types of injuries particularly needle stick injuries (NSI) places the healthcare workers
and patients at risk for transmission of infection. The agency also stated The greatest risk of
infection transmission is through percutaneous exposure to infected blood (p. 3).
Internationally, occupational or work related exposure to blood and body fluids remains the
number one cause of occupational hazards for healthcare workers, particularly for nurses. Needle
stick injuries occupy the largest percentage among the occupational hazards. Needle stick
injuries vary from deep wound, middle, and surface wound injuries (Gourni, Polikandrioti,
Vasilopoulus, Mpaltzi, & Gourni, 2012).
A great number of researches currently are being done to determine and establish the risk of
blood and body fluid exposure to healthcare workers and the importance of protecting these
workers. In every hospital whether developing or developed countries, the risk of contamination
or transfer of infection through percutaneous exposure remains to be a threat. As a result,
development of an effective program for prevention and management of percutaneous injuries to
infected blood or body fluids is pivotal.
Gourni et al. (2012) stated, It is widely accepted that the most common occupational hazards
for all healthcare professionals involved in clinical care are the needlestick and sharps injuries
mainly caused by inadequate disposal and recapping of needles (p.64). The authors added that
exposure to blood and urine is considered to be the most frequent danger.
Problem and Mission Statement

THE QUALITY IMPROVEMENT APPLICATION

Gharyan University Teaching Hospital, formerly known as Gharyan Hospital is the only
medical hospital in the city of Gharyan. Gharyan is a village located in the Nafousa Mountains in
the Northwest part of Libya with a population of 85,219. One of the defining characteristics of
the hospital is that, it has been considered as the training institution for medical, nursing, and
paramedical students of Al Jabal Al Gharbi University.
Gharyan Hospital was established when the city of Gharyan needed a facility to deal with the
health care needs of the community. The hospital has a 300-bed capacity, capable of admitting
and managing medical, surgical, gynecologic, pediatric, critical care, communicable/infectious,
and trauma cases. This institution is entirely government owned and all of the services provided
including medications and treatments are free for the citizens of Gharyan.
Since the start of the revolution, Gharyan University Teaching Hospital became the central
hospital in the whole Nafousa Mountains. Majority of admissions were from the neighboring
cities, which cannot be handled by their local medical centers. This situation places all the
healthcare personnel at risk for blood and body fluid infection transmission.
Quality improvement plans which focuses on needle stick injury, including awareness,
prevention, and management will benefit the organization. Chow, et al. (2009) added This
requires more than a commitment to the policy of a safe work practices, it requires a leadership
culture that is devoted to the concept of working safely and reducing risk, acquiring and sharing
information about workplace safety concerns, maintaining rigorous safety management systems
and the practice of regularly auditing and improving information and management systems
(p.125).

THE QUALITY IMPROVEMENT APPLICATION

In the Arab-Muslim countries, a number of studies were conducted to determine the

frequencies of needlestick injuries. These studies not only provide benchmarks for quality
improvements but recommends effective approaches to prevent this type of injuries. Since,
Gharyan University Teaching Hospital has no available data on needlestick injuries, these results
can be beneficial in setting standards in the organization.
In a study done in Egypt, it was revealed that 66.2% of healthcare workers had experienced
any form of needlestick injuries and this was due to a lack of infection control policy (Ismail,
Aboul, El-Shoubary, & Mahaba, 2007). Askarian, Shaghaian, & McLaws (2007) indicated that
needle stick injuries in Iran, especially among nurses, are high with a rate of 4 NSIs in a year.
Consequently, Mobasherizadeh, Abne-Shahidi, Mohammadi, Yazdani, & Abazari (2007)
strengthens these claims in Iran stating that injury resulting from contaminated sharp devices
among healthcare workers (HCWs) is one of the most important concerns in medical centers
(p.209). The authors recommended an effective and appropriate program for the disposal of
sharp devices and utilizing safe needle devices.
The risk of exposure to blood-borne pathogens (BBPs) remains a huge problem in Lebanon
and an immediate implementation of an infection control standards were needed to reduce the
increasing trends exposure (Musharrafieh, Bizri, Nassar, Rahi, Shoukair, Doudakain, 2008). The
United Arab Emirates, an investigation was done and revealed that sharp injuries for doctors
were caused by suture needles and 50% of injuries occurred among nurses were caused by
hollow-bore needles (Ganezak, Barss, Al-MArashada, Al-MArzouqi, & Al-Kuwaiti, 2007. Gouri
et al. (2012) emphasized, Prevention and control strategies of exposure to blood and body fluids
in conjunction with proper education are the key-factors for the solution of this problem (p. 60).

THE QUALITY IMPROVEMENT APPLICATION

In Gharyan University Teaching Hospital an informal survey was done to determine the
incidence of needlestick injuries among nurses. The informal survey revealed that most of the
nurses employed in the hospital had an incident of needlestick injuries in the first quarter of this
year. The highest unit with the most NSIs was in Hemodialysis Unit, averaging to four to five
NSIs per day. Second was in the Adult Intensive Care Unit with 10 NSIs, three of this injuries
were from a HBV positive patient. Third was in the OB-Delivery Room with eight NSIs and
lastly in the Trauma-ER Unit with five cases. These cases were not properly reported because
there is no policy in place for needlestick injuries in the organization.
The quality improvement project will be focusing on the development of a policy, which will
manage needlestick injuries in the organization. Policies as defined by Dayson (1999) are the
guiding principles by which service is provided (p.12). The author explained that policies and
procedures assist all organizations with their decision-making and how the work is supposed to
be done in that organization. Kelly (2011) stressed, policy initiatives have historically targeted
the quality of the structural elements of the healthcare delivery system, such as people, physical
facilities, equipment, and drugs (p.120). The author added that these initiatives focus on the
results and processes of the organization and provider levels.
Quality Improvement Model
The Juran Model of Quality Management identified Quality Improvement as one of the
important aspects of the Quality Management Cycle along with Quality Planning and Quality
Control Measurement. According to this model, Quality Improvement (QI) determines causes of
process failure, alterations and ineffectiveness, and analytically proposes solutions to defects in
the process. QI also critically considers data for better or best practice (Brown, 2010).

THE QUALITY IMPROVEMENT APPLICATION

The appropriate quality improvement model for the quality improvement initiative for
Gharyan University Teaching Hospital will be the Jurans Quality Improvement Process (QIP).
Brown (2010) explained that this approach is composed of four important steps that will assist an
organization in identifying prioritized areas, collecting data, initiate action for change, determine
effective team, and assess improvement. The four steps are:

Step 1: Project Definition and Organization

Step 2: Diagnostic Journey

Step 3: Remedial Journey

Step 4: Holding the Gains

The quality improvement team that will be identified in the Adult Intensive Care Unit of the
Gharyan University Teaching Hospital will first identify the problem, in this case, needlestick
injuries in the unit. The team then will consolidate on the development of a policy regarding
NSIs in in the ICU. The next step will be on identifying root causes and formulating cause
theories application to the unit. As part of the remedial journey, the team will consider a draft
policy on need stick injuries in the unit as an alternative solution to the problem. This policy will
be pilot tested in the unit with the implementation and results documented. Checking the
performance of the unit regarding NSIs management will be holding the gains step of the QIP.
The sample policy for NSIs in the ICU is shown below.

THE QUALITY IMPROVEMENT APPLICATION

GHARYAN UNIVERSITY TEACHING HOSPITAL

GHARYAN, LIBYA
Document ID
NSI 01
Revision
XX
Effective Date
XX
Program
Area (s)

Title
Needle Stick Injury Protocol
Prepared by:
Date:
Anthony F. Gomez, PTRP, BSN, RN, MSN, XX
LEU, DNPs
Reviewed by:
Date:
Dr. XX - Head - ICU Department
XX
Approved by:
Date:
Dr. XX - Deputy Medical Director
XX
Facility and Unit based crisis

Purpose: To set forth mechanisms and processes for the management of needed stick injuries.
Policy:

1. This policy includes assessment and management of needlestick injuries

among healthcare workers at Gharyan University Teaching Hospital.
2. This policy is intended for all healthcare workers employed at Gharyan
University Teaching Hospital.
3. This policy is intended to provide proper reporting, assessment, and
management of needlestick injuries in all areas or unit of Gharyan University
Teaching Hospital.

Procedure:

1. Upon exposure or needle stick injury, rinse with water. Disinfect with 70%
alcohol and rinse mucous membrane with water.
2. Reports to the Head Nurse.
3. The Head Nurse will accomplish the Needlestick Injury Report Form.
4. If injury from a non-infectious patient, there will be no action needed.
5. If injury from an infectious patient, refer to Tripoli Central Hospital
Infection Control Committee for Anti-body titer testing, immunoglobulin
administration, and follow up management.
6. If the injury is from a positive Hepatitis B virus patient, determine if the
healthcare worker has past HBV or full vaccinations. If the healthcare worker
has a full vaccinations or past HBV, no action is needed.
7. If the injury is from a positive Hepatitis B virus patient, determine if the
healthcare worker has past HBV or full vaccinations. If the healthcare worker
has no full vaccinations or past HBV, administer HBIG in less than 48 hours.
8. If the injury is from a positive Hepatitis C virus patient, follow up after 9-12
months. If the HVC is negative, no action needed.
9. If the injury is from a positive Hepatitis C virus patient, follow up after 9-12
months. If the HVC is positive, administer Alpha-interferon and Ribavirin.
10. If the injury is from a positive HIV patient, immediate PEP Test Source is
done and follow-up after 1, 3, and 6 months.

THE QUALITY IMPROVEMENT APPLICATION

11. If the injury is from a positive HIV patient, immediate PEP Test Source is
done and follow-up after 1, 3, and 6 months and if the test is positive,
immediate treatment by AIDS expert.
12. If the injury is from a positive HIV patient, immediate PEP Test Source is
done and follow-up after 1, 3, and 6 months and if the test is negative and no
infection stop the PEP.

The sample draft for Needle Stick Injury Guideline is shown below.

Needlestick Injury Management Guideline

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10

Rinse wound with water

Exposur
e

Disinfect with 70% alcohol

Rinse mucous membrane with water

Report to the Head Nurse

No

No Action

Infectio
us
Yes
Yes
Refer
Tripoli
Refer --Y
Tripoli
Central
Central

Hospital
Hospital

Follow Up

HBV

HBV
HBV or
or
Full V
Full
V

HBC

Positive
Positive
follow
follow up
up
after
after 9-12
9-12
months
months

Primary Measurement
Measurement indicators here
obtain

HIV

medical institutions are

No Action

Yes

HBIG < 48 hrs

No

HVC
+

Yes

Alpha-Interferon
Alpha-Interferon and
and Ribavarin
Ribavarin

No

in Libya are

or
PEP

No Infection

Yes

usually

difficult to

PEP
PEP follow
follow up
up after
after
1,3,6
1,3,6 months
months

STOP

none at all because

HIV
HIV --

Yes
No

Treatment
Treatment by
by
AIDS
AIDS Expert
Expert

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under the Ministry of Health of Libya, which does not usually gathers data for measurement.
Measurement indicators for quality improvement or quality management are not yet
accomplished in this country. Instead, the team will make use of data form neighboring ArabMuslim countries for comparison.
Manzour, Daud, Hashmi, Sardar, Babar, Rahman, & Malik (2010) reported that in Pakistan
71.9% of nurses in a tertiary health care facility had NSIs. The authors also noted that in Saudi
Arabia, 16.5% of nurses (0.21 and 0.38 injuries/person/year) experienced NSIs in 2009.
Galougahi (2010) indicated that in Iran, 56.96% of healthcare workers in Khanevade Hospital
had a history of at least one needlestick injury in 2009 and concluded that this rate was
significantly less than other similar studies in Iran.
The initial overall goal of the team will be to have a proper reporting and management of
needlestick injuries in Gharyan University teaching Hospital. The Centers for Disease Control
and Prevention (2013) stressed the importance of sharps injury reporting as part of baseline
assessment for effective prevention planning. This reporting, which is part of the proposed
protocol on NSIs will provide the team meaningful data which can be utilized for internal
benchmarking, researches, and basis for program development.
Strategies for Managing Ethical Dilemmas
The current situation of the healthcare system of Libya requires a number of foreign trained
healthcare workers specially nurses to fill the countrys demand for healthcare services. In
Gharyan University Teaching Hospital, majority of nurses are nonnative particularly in special
areas like ICU. These nurses are from the Philippines, Ukraine, Romania, India, Bangladesh,
Jordan, Egypt, and Tunisia. With healthcare workers of different nationalities, culture, and
religion, reporting of needlestick injuries might be difficult to attain.

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Managing this type of issue can be done through an establishment of a culture of safety. As
CDC (2013) stated To create a culture of safety, organizations must address those factors known
to influence employees attitudes and behaviors. Organizations must also direct measures to
reduce hazards in the environment (p. 38). The agency pointed out that encouraging healthcare
workers to report any type of injuries would foster a culture of safety and create a blame-free
environment.
Team Description
When a group of individuals joined together to work for a purpose, they are building a team,
which according to Kelly (2011) may comprise specialties within a single discipline, across
departments, or across organizations (p. 192).
The Juran Institute (2013) explained the importance of a team for completing a project, which
should be multifunctional in nature. This approach will ensure that individual biases will be
minimal because everyone is well represented. The CDC (2013) further explained,
Representation of staff from across disciplines ensures that needed resources, expertise, and
perspectives are involved. The responsibility and authority for program coordination should be
assigned to an individual with appropriate organizational and leadership skills. The team should
also include persons from clinical and laboratory services who use sharp devices, as well as staff
with expertise in infection control, occupational health/industrial hygiene, in-service training or
staff development, environmental services, central service, materials management, and
quality/risk management, as available (pp. 24-25).
Since the planned quality improvement will only be applied in the ICU, a functional team
composed of nursing staff of different nationalities will be selected. A functional team will be
beneficial because the QI plan aims to improve processes in the area. A Filipino nurse with

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extensive experiences in the Middle East, a Jordanian nurse from International Medical Corps, a
Syrian nurse, a Libyan nurse from the BSN Program will be part of the team. The head of the
ICU Department and the Manager for Infectious Control Office will also be included as part of
the team. These members were chosen primarily because of their educational and employment
background. Also, these nurses has the ability of using the English and Arabic languages
effectively, therefore, limiting communication barriers. The strength of the members of the team
will be as follows:
1. Head of the ICU Department - a medical doctor that will represent the
Administration/Senior Management. This person will serve as the means of
communication form the ICU to the top-level managers and will be the facilitator during
meetings.
2. Manager of Infection Control Office - this person will assess infection control
implications and sharps injury prevention programs.
3. Filipino Nurse with extensive experience in the Middle East - this person will serve as the
In-service Trainer/Staff Developer, which will provide information on current education
and training practices and will explain proposed protocol and any educational
interventions.
4. Jordanian Nurse from the International Medical Corps - this person will be the Risk
Control/Quality Manager, which will help design process related to the needlestick
protocol.
5. Syrian and Libyan Nurse - these people will be the Front-line Clinical and Laboratory
Staff, which deliver insight into the proposed protocol and will have an active
participation in the evaluation of the protocol.

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The meeting of the team will be done every Friday morning, since this is the only available
day for the members to convene due to schedule restrictions. One member of the team will take
appropriate documentations of everything that took place in the meeting. The documentations
will be then sent to the Office of the Deputy Medical Director for proper communication.
Participative Management Paradigm used by the Japanese is appropriate in order for the QI
plan to succeed in the organization. Brown (2013) explained that this type of management would
foster enthusiasm among workers if they feel they are safe and secure, sharing of information is
practiced, employees are active participants which places its people first, and people are
empowered by including them in decision making process. By utilizing this type of participative
management, members of the team will be motivated because the feeling of involvement in the
process is present.
Leadership Qualities
The Head of the ICU Department will be the leader of the team. The leader will have shared
and unshared responsibilities for the attainment of the project. The Juran Institute (2013)
explained that the leader has the oversight obligation which will motivate the members to
contribute and will assist in resolving conflicts that may arise. The leader should have multiple
skills and must be trained appropriately to handle people, have a strong background about the
subject matter and of the quality improvement process.
The leader of the team will inspire every member to function maximally, exhausting every
effort to achieve the goal. By doing this, the person will evolve form a manager to a
transformational leader, which according to Zaccagnini & White (2011), lead with a clear vision
and use coaching, inspiring, and mentoring to transform themselves, followers, and

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organizations (p. 252). This leader will then do the right things instead of doing things right
(Brown, 2010).
Formulate EBP and an Action Plan to Achieve Improvement Outcome
As The Joint Commission (2013) stated When serious events occur, whether they involve
patients or employees, The Joint Commission expects health care organizations to conduct a root
cause analysis that is robust and non-punitive (p.13). The team believes that a root cause
analysis will be beneficial to address the issue of needlestick injuries in the organization. The
RCA Framework Template by the Joint Commission with 24 questions for analysis that can be
helpful on organizing the steps in a root cause analysis will be utilized.
Based on the root cause analysis done, it was noted that the defect in the organization was due
to a lack of protocol in needlestick injuries. Human factors include failure to follow established
policies/procedures. The equipment performance, availability, and condition have no
deficiencies. Environmental factors include safety and security risks, which are controllable. This
needlestick injury in the ICU Department has a probability of happening to other units such as
Trauma-ER, OB-Delivery Department, Hemodialysis Unit and Medical and Surgical Wards of
the Hospital. Regarding the staff, there was no orientation or training done on needlestick injury
prior or during the course of employment. There was no identified problem regarding the staffing
ratios, however, skill and experience level mix was a concern. There was neither plan nor
contingencies in an event when a healthcare worker experienced needlestick injury. Also there
was no failure-mode responses planned or have been testes in the organization.
After a comprehensive root cause analysis, the team will developed a draft protocol or policy
regarding needlestick injuries in the ICU unit. This policy or protocol will be pilot tested in the
ICU unit, documenting the implementation and results.

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Barriers of the Project

Communication barriers will be the major concern. Since most of the people in the
organization cannot understand English, conveying the plan to the top management will be a
challenge. The same is true with the involvement of the medical practitioners who cannot
understand well the English language. Since majority of the healthcare workers in the
organization are form different cultural backgrounds and using Arabic and English language as
the mode for communication, the team will eventually prepare two sets of documents. All the
documents that will be utilized, processed, and disseminated will be prepared using the English
and translated to Arabic language.
The Juran Institute (2013) identified communication errors as one of the sources of human
errors that can affect the success of the project. Although troublesome, most of these errors are
manageable. Of the identified communication errors, the team will be specific on Transmission
Errors. The Juran Institute (2013) explained, They arise from limitation in human
communication. Identical words have multiple meanings, so transmitter may have one meaning
in mind, but the receiver has a different meaning in mind (p.64). To remedy these difficulties,
the team will be very meticulous in translating word or words and ascertain that every document
translated has its direct and exact meaning.

Summarize the Impact of the Team Process

The team made use of the Juran Quality Improvement Process and Root Cause Analysis in
order to develop a draft policy or protocol that will address the issue of needlestick injuries in the

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ICU Department. Each step of the Quality improvement Process will take at least two months
each, and the last step, three months. Within the first five months, the team will have a clear and
defined project with an ongoing functional team. This will be evidenced by a development of a
draft policy or protocol for needle stick injury.
Within this period, the team will be able to determine the root cause of the problem,
determination of theories and testing them, and finally be able to determine the defects in the
process. The remaining four months will be allotted to the testing of the draft protocol or policy
regarding needle stick injury. By this time, there will be proper reporting of any sharp injuries in
the unit and the team will be able to have a baseline data to present.
These data will then be utilized to determine standards within the organization and will be
used for research and possibly the basis for another program development. This vital information
will also be considered as the basis for revising the protocol and making it a standard protocol to
be used by the hospital. After the nine-month period, the hospital will have a standard protocol
for needlestick injury and will be utilized by every unit to prevent, report, and manage these
injuries.
Summary of the Team Process in Creating Improvement
The Juran Institute (2013) stated, Numerous companies have initiated quality improvement,
but few have succeeded in institutionalizing it so that it goes on year after year (p. 67). The
teams goal for this organization is not just to initiate a quality improvement project but also to
institutionalize the change. The team believes that by doing these initiatives, Gharyan University
Teaching Hospital might be a model institution here in Libya where quality management is
taking place. As a training institution, the hospital can train not only the future health workers of
Libya but the future quality managers as well.

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The goal of the team to address the issue of needlestick injuries in the ICU Department will
be successful only if there will be an effective reporting of every incident to be able for these
injuries to be managed appropriately. Without the reporting of cases, the organization will have
no baseline data to use. The team leader will demonstrate the skill and ability of a
transformational leader, which will motivate the team members to work effectively and
efficiently.
The team will do their part by functioning according to their designated roles and
responsibilities, able to meet the demands of the project. Every meeting will be properly
documented and communicated to the top management for information dissemination. An open
line of communication will be open to all members of the team, respecting their own beliefs,
culture, and religion. Proper and appropriate translations will be done to ensure everyone
understands the totality of the project.
Conclusion
The healthcare delivery system of Libya is in chaos and this is evident by lack of quality
management in most of its branches. In Gharyan University Teaching Hospital where resources
are readily available, quality management is pivotal to manage these resources and produce
patient satisfaction. This can be done through a Quality Improvement initiative. Commencing in
a single unit with a problem that can be addressed by applying quality management principles
and evidence-based practice, will foster changes that can influence the whole healthcare delivery
system of the country.
References
Askarian, M., Shaghaghian, S., & McLaws, M. (2007). Needlestick injuries among nurses of
Fars province Iran. Annals of Epidemiology, 17, 988-992.

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Brown, J. A. (2010). The Healhcare Quality Handbook: A professional Resource and Study
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Centers for Disease Control and Prevention (2013). The National Healthcare Safety Network
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http://www.cdc.gov/nhsn/acute-care-hospital/clabsi/index.html#sm
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http://www.cdc.gov/sharpssafety/pdf/sharpsworkbook_2008.pdf
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injury: A novel intervention to reduce the occupational healht and safety risk in the
haemodialysis setting. Journal of Renal Care, 120-125.
Dyson, M. (1999). How and when to write policies and procedures (2nd ed.). Victoria, Australia:
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the United Arab Emirates. Infection ontrol and Hospital epidemiology, 28, 751-54.

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Gourni, P., Polikandrioti, M., Vasilopoulus, G., Mpaltzi, E., & Gourni, M. (2012). Occupational
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Ismail, N., Aboul, F., El-Shoubary, W., & Mahaba, H. (2007). Safe injection practice among
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Kelly, D. L. (2011). Applying Quality Management in Healthcare: A Systems Approach (3rd ed.).
Chicago, IL: Health Administration Press.
Manzoor, I., Daud, S., Hashmi, N., Sardar, H., Babar, M., Rahman, A., & Malik, M. (2010).
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of needle stick injury in Iran. Saudi Medical Journal, 26, 1225-7.
Musharrafieh, U., Bizri, A., Nassar, N., Rahi, A., Shoukair, A., & Doudakian, R. (2008).
Healthcare workers' exposure to blood-borne pathogens in Lebanon. Occupational
Medicine, 58, 94-98.
The Joint Commisiion (2013). Joint Commission: Serious HCW injuries are now sentinel events.
Hospital Employee Health, 32(2), 13-24.
The Joint Commission (n.d.). Topic Details | Joint Commission. Retrieved May 2, 2013, from
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nd_Action_Plan/

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The Juran Institute (n.d.). The Source for Breakthrough - Juran. Retrieved May 10, 2013, from
http://www.juran.com
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model for advanced practice nursing. Sudbury, MA: Jones & Bartlett Publishers.

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