1. Create a 1-page “swim lane” flowchart (process map) of Carla’s journey, beginning from Day 1 to her transfer into a long-term care facility. Illustrate the pathway of Carla’s journey through various settings, using symbols and words.
2. Create a 1-page cause and effect diagram (fishbone diagram). Identify a single sentence that clearly and specifically states the WHO, WHAT, and WHERE of the problem (i.e. “fish head”). Identify 4-6 major categories that contributed to the problem (i.e. “big bones”), the causes of the problem (i.e. “small bones”), and the reasons why (i.e. “smaller bones”). Conduct the five “whys” exercise to get at the “smaller bones.”
3. Write your paper. Use the outline below to inform the structure and content.
Assignment outline
Sub-headers to use:
Address these areas:

Provide a brief overview of the paper. What is your paper going to do?
Problem Situation
Provide a backdrop to the situation that led to Carla becoming the youngest resident in the long-term care facility. Who is Carla? What is Carla’s story about? Where does Carla’s story take place? This is a summary of the case for your analysis to emerge in subsequent sections of your paper.
Key Constructs
Define and describe:
• “The Chain of Effect: A Framework for Understanding,” including the meaning of Levels A, B, C, and D of the healthcare system.
• The “Swiss cheese model.” Explain how it can be used with “The “Chain of Effect” framework to analyze systems.
Patient-Centered Care?
Oppose or support the argument that Carla’s story is an example of patient-centered care.
• Identify and describe the level(s) of the healthcare system (e.g., Levels A, B, C, or D) where major problems occurred in Carla’s story.
• Identify and describe what the active failures and latent conditions were that contributed to the problem.
• Using the “Swiss cheese model,” assess how “the holes in the defenses” lined up, leading to Carla’s outcome.
Apply examples from the case study to relevant key constructs. Provide evidence from the case study to substantiate your claims. Refer readers to your flowchart and cause and effect diagram in the appendix as needed.
Provide concluding remarks about how an analysis of Carla’s story is applicable to healthcare systems more broadly.
• Make an argument for why changes at Level B or C is an appropriate level to intervene in the healthcare system.
• Propose two (2) IOM Rules for Redesign that could be used to improve the healthcare system to yield a different outcome for future patients like Carla, and explain why (continuous healing, customized care, patient control, shared knowledge, evidence-based care, care system safety, transparency, anticipated needs, decreased waste, clinician cooperation).
• Which one (1) of the six IOM Aims for Improvement would be addressed by your proposals, and why? (improve safety, effectiveness, patient-centeredness, timeliness, efficiency, or equity)
Provide a list of all relevant references cited in the paper.
Paste your flowchart and cause and effect diagram to the end of your paper. These should be created in a professional scholarly manner (not handwritten).




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