PUQ213 Quality Management in Health

Assignment 1B: Workbook activities submission 2

Word limit: 1800 words per submission (3600 total) (+/- 10%)

References: 20 up to date 2014-2021 or alternatively references used in this teaching module.

For this assignment you must complete six workbook activities that relate to Modules 1–4. Completing these workbook activities will help focus your learning as you will be:

  1. identifying the key concepts and principles of quality in health and aged care settings
  2. exploring issues of significance in implementing quality and patient safety systems.  

Assignment overview

This page details the three workbook activities that relate to Modules 2, 3 and 4 and must be completed for your first submission. See Assignment 1: Workbook activities instructions for recommended steps to follow for completion of these activities and the marking criteria against which you will be assessed.

This assignment supports unit learning outcomes 1 and 2.

Assignment details

Workbook activity 4

Note: This activity relates to Modules 2/3 and is worth 20 marks. 

While there has been hard evidence of unacceptable safety performance existing in modern health care for the past three decades, high profile health system failures of the last fifteen to twenty years led to change. These failures have illustrated risks and lack of accountability, caused public mistrust of the healthcare system, and highlighted the need for greater controls.

To complete this activity, you will need to read the background and relevant findings sections of two of the following reports (see the page number details that will direct you to the specific sections needed):

Workbook activity 4 reference material

Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry  (The Mid Staffordshire NHS Foundation Trust, 2013).


The Oakden Report (Links to an external site.) (Groves et al., 2017).

  • Background (pp. 1–2).
  • Term of reference – Quality and safety of care (pp. 69–92).
  • Term of reference – Culture (pp. 93–101).

Alternatively, you may wish to look at:

Oakden: A shameful chapter in South Australia’s history (Links to an external site.) (Lander, 2018).

  • Executive summary (pp. 14–16).
  • Chapter 1 Introduction: How this investigation came about (pp. 22–25).
  • Chapter 6 The Oakden Report (pp. 115–131).

Learning from Bristol, The Report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984 – 1995 (Links to an external site.) (Department of Health, 2001). 

  • Chapter 1 Background to this enquiry (pp. 23–25).
  • Chapter 6 Quality Standards and Information (pp. 74–85).
  • Section ‘Responses within the UBH/T’ in Chapter 12 Response to concerns and actions taken, and whether such actions were appropriate and prompt (pp. 159 –176).

In addition, there is extensive background information about the regulatory and clinical practice environment at the time of the inquiry and an extensive section Chapter 21 to 29 based on the guiding principles for recommendations. You may also like to have a look at the following resource as it provides a good summary: This article ‘A very public failure: Lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary (Links to an external site.)‘ (Walshe & Offen, 2001, pp. 250–256).


The Report of the Morecombe Bay Investigation (Links to an external site.) (Kirkup, 2015).

  • Executive summary (pp. 7–11).
  • Chapter 1 Investigation findings (pp. 13–29).
  • Chapter 8 Conclusions and recommendations (pp. 183–199).
  • Recommended Conclusions Chapters 3 and 4 (pp. 49–103).

Queensland Public Hospitals Commission of Inquiry Report (Links to an external site.) (Davies, 2005) focus only on the Bundaberg Base Hospital information.

  • Chapter 1 Report summary (pp. 1–6, 15–17).
  • Scan for key themes which are clearly labelled in Chapter 3 The Bundaberg Base Hospital (pp. 41–197). 
  • Scan for key themes in recommended reading Chapter 6 Common causes and suggested remedies (pp. 343–579).

There are five tasks that must be completed for this activity:

Workbook activity 4 tasks
Task 1
(10 marks)
Use a table format to identify common factors that contributed to the adverse events described in the reports and note which of these are system or individual factors. 
Task 2 
(3 marks)
Why are causal and contributing factors classified as system or individual factors? 
Task 3
(2 marks)
Almost all of the hospitals that were the subject of inquiries were accredited. Why were the problems identified during the inquiries not identified through accreditation? 
Task 4 
(2 marks)
Why is health and aged care so susceptible to these types of harm? 
Task 5
(3 marks)
How effective do you think public inquiries are in achieving long term improvement in the quality and safety of health services? Provide some reasons for your answer. You may like to refer to the following readings in your response: There’s a long list of NHS inquiries, but what have they actually changed? (Links to an external site.) (Vize, 2016).Chapter 12 Scandals, public inquiries and health professional regulation in ‘Health workforce governance (Links to an external site.)‘ (Short, 2012, pp. 223–243).  

Workbook activity 5

Note: This activity relates to Modules 3/4 and is worth 15 marks. 

It will be clear from your readings about the public inquiries into major patient safety failures that a number of common themes are described. These include: 

  • a lack of leadership for quality and safety
  • failure to act rather than failure to know about problems
  • a professional culture that is a major barrier to improved safety, and
  • that teamwork and communication are as important as technical competence to the provision of safe, high quality care. 

There are four questions that must be answered for this activity:

Workbook activity 5 questions
Question 1
(4 marks)
What is the impact of organisational culture on health care quality and safety? 
Question 2
(3 marks)
What type of culture best supports the delivery of high quality, safe care? Provide reasons for your answer.
Question 3
(5 marks)
What is a safety culture? 
Question 4
(3 marks)
Why is person-centred care integral to a safety culture? 

You will need to incorporate evidence into your response to each question. To assist you in doing this, additional reference materials have been provided. You are not required to read all of this material, however each of the four questions should provide evidence from at least one of these reference materials.

Select the following heading for a list of the reference material to be used in this activity:

Workbook activity 5 reference material

Workbook activity 6

Note: This activity relates to Modules 3/4 and is worth 30 marks. Your answer to this activity should be completed in no more than 500 words.

The concept of clinical governance has evolved from the need to significantly improve organisational management of the quality of health care. As evidenced by public safety failures and high rates of adverse events, the application of corporate governance has been seen as an inadequate safeguard for clinical quality and safety. Further, the increasing complexity of health care has resulted in process and systems improvements that cross professional and clinical unit/service boundaries. This, in turn, has generated a move towards more integrated, organisational and cross organisational approaches to quality improvement. With the introduction of the Australian National Safety and Quality Health Service (NSQHS) Standards, a National Model Clinical Governance Framework has been developed. The elements that make up this framework are mandatory for Australian health care organisations to meet the requirements of the standards. 

There is one task that must be responded to for this activity:

Workbook activity 6 task
Task 1
(30 marks)
What is clinical governance? Why is a system of clinical governance necessary in health and aged care organisations? What are the common elements of clinical governance frameworks? From your reading and experience, what are some of the barriers that organisations will need to address in order to ensure the effective adoption of clinical governance?  

You will need to incorporate evidence into your response to this task. To assist you in doing this, additional reference materials have been provided. You are not required to read all of this material, however you should provide evidence from at least one of these reference materials.

Select the following heading for a list of the reference material to be used in this activity:

Workbook activity 6 reference material

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