Quality Improvement Initiative Evaluation Essay.

Quality Improvement Initiative Evaluation Essay.

 

Deliver a 5–7-page analysis of an existing quality improvement initiative at your workplace. The QI initiative you choose to analyze should be related to specific disease, condition, or public health issue of personal or professional interest to you.Quality Improvement Initiative Evaluation Essay.

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Too often, discussions about quality health care, care costs, and outcome measures take place in isolation—each group talking among themselves about results and enhancements. Because nurses are critical to the delivery of high-quality, efficient health care, it is essential that they develop the proficiency to review, evaluate performance reports, and be able to effectively communicate outcome measures related to quality initiatives. The nursing staff’s perspective and the need to collaborate on quality care initiatives are fundamental to patient safety and positive institutional health care outcomes.Quality Improvement Initiative Evaluation Essay.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

  • Competency 2: Plan quality improvement initiatives in response to routine data surveillance.
    • Recommend additional indicators and protocols to improve and expand quality outcomes of a quality initiative.
  • Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.
    • Analyze a current quality improvement initiative in a health care setting.
    • Evaluate the success of a current quality improvement initiative through recognized benchmarks and outcome measures.
  • Competency 4: Integrate interprofessional perspectives to lead quality improvements in patient safety, cost effectiveness, and work-life quality
    • Incorporate interprofessional perspectives related to initiative functionality and outcomes.
  • Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
    • Communicate evaluation and analysis in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
    • Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.

The purpose of the report is to assess whether specific quality indicators point to improved patient safety, quality of care, cost and efficiency goals, and other desired metrics. Nurses and other health professionals with specializations and/or interest in the condition, disease, or the selected issue are your target audience.Quality Improvement Initiative Evaluation Essay.

Questions to Consider

As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.Quality Improvement Initiative Evaluation Essay.

 

Reflect upon data use in your organization as it relates to adverse events and near-miss incidents.

  • How does your organization manage and report on adverse events or near-miss incidents?
  • What data from your organization’s dashboards help inform adverse events and near-miss incidents?
  • What additional metrics or technology are you aware of that would help ensure patient safety?
  • What changes would you like to see implemented to help the interprofessional team better understand data use and data trends as quality and safety improvement tools?Quality Improvement Initiative Evaluation Essay.

Suggested Resources

Quality Improvement Initiatives

These resources explore how quality initiatives are applied in clinical settings.

  • Vachon, B., Desorcy, B., Gaboury, I., Camirand, M., Rodrigue, J., Quesnel, L., . . . Grimshaw, J. (2015). Combining administrative data feedback, reflection and action planning to engage primary care professionals in quality improvement: Qualitative assessment of short term program outcomes. BMC Health Services Research15, 1–8.
  • Abdallah, A. (2014). Implementing quality initiatives in healthcare organizations: Drivers and challenges. International Journal of Health Care Quality Assurance27(3), 166–181.

This article addresses competing quality improvement projects in organizations.

  • Nyström, M. E., Garvare, R., Westerlund, A., &Weinehall, L. (2014). Concurrent implementation of quality improvement programs: Coordination or conflict?International Journal of Health Care Quality Assurance, 27(3), 190–208.

Benchmarks for Quality Indicators

These databases provide recognized benchmarks for quality indicators.

  • Montalvo, I. (2007).The national database of nursing quality indicators. Online Journal of Issues in Nursing12(3), 1–11.
  • The Joint Commission. (2017). National patient safety goals. Retrieved from
  • Assessment Instructions

Preparation

You have been asked to prepare and deliver an analysis of an existing quality improvement initiative at your workplace. The QI initiative you choose to analyze should be related to a specific disease, condition, or public health issue of personal or professional interest to you. The purpose of the report is to assess whether specific quality indicators point to improved patient safety, quality of care, cost and efficiency goals, and other desired metrics.Quality Improvement Initiative Evaluation Essay.

Your target audience consists of nurses and other health professionals with specializations or interest in your selected condition, disease, or issue. In your report, you will define the disease, analyze how the condition is managed, identify the core performance measurements used to treat or manage the condition, and evaluate the impact of the quality indicators on the health care facility:Quality Improvement Initiative Evaluation Essay.

The numbered points below correspond to grading criteria in the scoring guide. The bullets below each grading criterion further delineate tasks to fulfill the assessment requirements. Be sure that your Quality Improvement Initiative Evaluation addresses all of the content below. You may also want to read the scoring guide to better understand the performance levels that relate to each grading criterion.Quality Improvement Initiative Evaluation Essay.

  1. Analyze a current quality improvement initiative in a health care setting.
    • Evaluate a QI initiative and explain what prompted the implementation. Detail problems that were not addressed and any issues that arose from the initiative.
  2. Evaluate the success of a current quality improvement initiative through recognized benchmarks and outcome measures.
    • Analyze the benchmarks that were used to evaluate success. Detail what was the most successful, as well as what outcome measures are missing or could be added.
  3. Incorporate interprofessional perspectives related to initiative functionality and outcomes.
    • Integrate the perspectives of interprofessional team members involved in the initiative. Detail who you talked to, their professions, and the impact of their perspectives on your analysis.Quality Improvement Initiative Evaluation Essay.
  4. Recommend additional indicators and protocols to improve and expand quality outcomes of a quality initiative.
    • Recommend specific process or protocol changes as well as added technologies that would improve quality outcomes.
  5. Communicate evaluation and analysis in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
  6. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.

Submission Requirements

  • Length of submission: A minimum of five but no more than seven double-spaced, typed pages.
  • Number of references: Cite a minimum of four sources (no older than seven years, unless seminal work) of scholarly peer reviewed or professional evidence that support your interpretation and analysis.Quality Improvement Initiative Evaluation Essay.
  • APA formatting: Resources and citations are formatted according to current APA style and formatting.

Preventable adverse events occur in the healthcare organizationdue to unsafe care. Their prevalence is the relatively highcompromising quality of care and patient safety in medical facilities(Schwendimann et al., 2018).According to the World Health Organization (2019), these events are ranked among the first ten causes of disability and death worldwide. Approximately one in every ten patients is a victim of adverse events in high-income countries. Low- and middle-income countries (LMICs) experience about 134 million adverse events annually due to unsafe care. These events lead to around 2.6 million deaths(World Health Organization, 2019).Quality Improvement Initiative Evaluation Essay. Although care providers learn from these events, they cause inconveniences to individual patients and their family members and the entire healthcare organization(Rafter et al., 2014). For instance, adverse events increase the total hospital activity and expenditure by 15%. On the other hand, adverse events increase hospital stay length and the total cost of care. These events also expose victims to physical and psychological torture. Some patients become permanently disabled, while others lose their lives due to adverse events. Additionally, these incidents expose family members to psychological and financial distress. People experience mental torture if one of their family members has become a victim of an adverse incident. They also use their financial resources to take care of the affected family member. While multiple adverse events have been witnessed in the healthcare organization, this paper will focus on a preventable patient fall in the critical care unit.Quality Improvement Initiative Evaluation Essay.

A Brief Description of the Event

The selected adverse event is a patient fall that occurred in the geriatric care unit. The fall involved Mrs. A,a 77-year-old African American female accompanied by her two daughters and a granddaughter during her first visit. Her daughters revealed that Mrs. A’s health has been deteriorating in the last six months. They stated that she has been struggling with T2D for the last ten years. She has been using insulin injections to reduce insulin production in the body, thus managing her condition. However, the Client had fallen several times at home in the previous month, making them seek medical attention. The presented symptoms and physical assessment indicated that she had dementia in addition to being diabetic.The care provider stated that the risk of falls was increased by her unstable diabetes. Diabetes increases the risk of falls among geriatric patients due to glycemic control loss (Yang et al., 2016).Quality Improvement Initiative Evaluation Essay.

Mrs. A was admitted to the geriatric unit for close monitoring by care providers. While in the hospital, Mrs. A became disorientated and fell as she tried to move out of bed to visit the washrooms. She sustained afracture in her right leg, which necessitated the performance of a surgical procedure. Consequently, the patient stayed in the hospital for a relatively more extended period, which raised her medical bills. Additionally, Mrs. A and her daughters developed a negative perception of the healthcare organization. The healthcare providers on duty denied being aware of her high risk of falls since her diabetes was being regulated.

Analysis of the missed Steps related to the Patient Fall

            The fall occurred due to a gap in the provided care. Healthcare providers failed to implement fall prevention interventions in the geriatric unit.The practitioners were not aware that adopting information technology interventions would enhance the safety of elderly patients in the geriatric unit. Information technology interventions, specifically wearable sensors, could enable the care providers tomonitorand analyze patients’ stability level. In turn, care providers would closely monitor the patient through hourly rounding and using call light upon realizing that her risk of falling was relatively high. Taking this measure could have prevented the patient from falling. Therefore, implementing wearable sensors in the geriatric unit is an effective fall prevention strategy.Quality Improvement Initiative Evaluation Essay.

Analysis of the Implications of the Patient Fall for all Stakeholders

The patient fall had both short-term and long-term effects on the stakeholders, including patients,interprofessional teams, healthcare organizations, and the community. The patient fall implies that multiple stakeholders have to prevent such adverse events from occurring in the healthcare organization. First, the incident implies that the organization’s management should introduce quality improvement initiatives, specifically information technology interventions to prevent patient falls. It is assumed that the management support quality improvement measures.Quality Improvement Initiative Evaluation Essay. Furthermore, patient fall implies that healthcare providers should utilizeinformation technology interventions, particularly the wearable sensorsin the geriatric unit. The use of sensors will enable them to monitor and analyze patients’ stability. Additionally, implementing wearable sensors will enable care providers to assessthe dynamic and static stability. This analysis is based on the assumption that healthcare providers will be trained in utilizing the proposed technology during care delivery. Lack of the necessary training might compromise the success of the proposed quality improvement initiative.Quality Improvement Initiative Evaluation Essay.

More so, the incident implies that IT experts should be involved in the delivery of care. The IT specialists will install and maintain information technology interventions, thus facilitating the proposed quality improvement initiative’s success. However, it is assumed that these experts are experienced in dealing with wearable sensors, which is the proposed information technology intervention for reducing the risk of falls.Besides, the adverse incident implies that patients, especially those in the geriatric unit, should be informed of the possibility of such events in the healthcare organization.Quality Improvement Initiative Evaluation Essay. Creating awareness will reduce the level of psychological torture the incident might have on the patient and their family members in case it occurs. Nonetheless, this implication is based on the assumption that the patients and their families are understanding. Lack of understanding might make them shy away from seeking care services from the medical facility claiming that patient safety and quality of care are compromised. Finally, the incident implies that the community should support the implementation of quality improvement initiatives. Measures such as information technology intervention prevent adverse events from occurring in the healthcare organization. It is assumed that the community is interested in the organization’s affairs, and it supports quality care and patient safety.Quality Improvement Initiative Evaluation Essay.

Metrics of the Patient Fall justifying the Need for Improvement

The incidence of patient falls in the geriatric unit has been increasing significantly.Consequently, patient falls are among the leading forms of in-hospital accidents. Approximately 70% of inpatient accidents are associated with hospital falls(Anderson et al., 2015).These falls result in severe physical and emotional injuries. Others lead to an increased length of hospitalstay, raising the health care cost. Extra hospital charges of over $4200 were incurred by patients who sustainedinjuries after falling (Anderson et al., 2015).Quality Improvement Initiative Evaluation Essay. Additionally, some patients are supposed to be admitted to a long-term care facility to receive continuous care after being discharged from the hospital. Research also shows that about 30% of hospital patient falls lead to physical injury where between 4% and 6% of these falls exposes patients to severe injuries, including subdural hematomas, fractures, and excessive bleeding(Anderson et al., 2015).Patient fall sometimes makes one fear of falling in the future. In turn, the fear of lowers mobility leading to muscle weakness, postural hypotension, contracture,and thrombogenicevents, thus lowering one’s quality of life.Quality Improvement Initiative Evaluation Essay.

Therefore, the high incidence of falls and associated health complications necessitate introducing measures of reducing falls in hospitals. Implementing quality improvement initiatives will prevent falls, thus boosting the quality of care and patient safety.

Proposed Quality Improvement Initiative to Prevent Patient Fall in the Future

The high rate of patient falls can be prevented by implementing a quality improvement initiative in the geriatric unit. Specifically, Mrs. A fell due to the lack of fall prevention interventions in the geriatric unit. Therefore, the event can be prevented from happening by introducing some quality improvement initiatives such as information technology interventions in the geriatric department. In particular, the use of wearable sensors will preventthe patient from falling through multiple strategies. According to Khalifa (2019), wearable sensors are highly reliable in monitoring and analyzing patients’ stability. Most healthcare providers use accelerometers and gyroscopes to detect stability and balance issues among geriatric patients. They place those sensors on the trunk to assess both the dynamic and static stability of a patient. Additionally, information technology analyzes the details of the falls and factors that exposed the patients to falls. Applications of technological devices also send data and alert care providers about the incidents of falls instantaneously. Therefore, implementing wearable sensors in the geriatric unit can reduce falls and increase patient safety.Quality Improvement Initiative Evaluation Essay.

In conclusion, patient falls are one of the most common adverse events in healthcare facilities. The risk of falls is relatively high among elderly patients who are hospitalized in the geriatric unit. The adverse event discussed in this paper involved a 77-year-old African American female. The patient was hospitalized in the geriatric care unit following repeated falls at home. She was diagnosed with diabetes and dementia. Unfortunately, the client became disorientated and fell as she tried to move out of bed to visit the washrooms. She sustained a fracture in her right leg, which necessitated the performance of a surgical procedure. Consequently, she stayed in the hospital for a relatively more extended period, which raised her medical bills. This incident was due to a missed protocol in the delivery of care. In particular, healthcare providers failed to implement quality improvement initiatives to enhance patient safety in the geriatric unit. Such events can be prevented from happening by introducing some quality improvement initiatives such as information technology interventions in the geriatric department. In particular, the use of wearable sensors will prevent the patient from falling. This technology will enable healthcare providers to monitorand analyze patients’ stability, thus implementing fall prevention strategies if the fall risk is relatively high. The event implied various stakeholders, including the multidisciplinary team, the community, and the patients and their family members.Quality Improvement Initiative Evaluation Essay.

  • Write a 6-page a comprehensive analysis on an adverse event or near miss from your professional nursing experience. Integrate research and data on the event and use as a basis to propose a quality improvement (QI) initiative in your current organization.
    Health care organizations strive for a culture of safety. Yet despite technological advances, quality care initiatives, oversight, ongoing education and training, laws, legislation and regulations, medical errors continue to occur. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation.Quality Improvement Initiative Evaluation Essay.
  • The goal of this assessment is to focus on a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities and to propose a quality improvement initiative to prevent future incidents.
    By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

    • Competency 1: Plan quality improvement initiatives in response to adverse events and near-miss analyses.
      • Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.
    • Competency 2: Plan quality improvement initiatives in response to routine data surveillance.
      • Analyze the missed steps or protocol deviations related to an adverse event or near miss.
      • Analyze the implications of the adverse event or near miss for all stakeholders.
      • Outline a quality improvement initiative to prevent a future adverse event or near miss.
    • Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.
      • Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement.
    • Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
      • Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
      • Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.
        Context
      • The purpose of the report is to assess whether specific quality indicators point to improved patient safety, quality of care, cost and efficiency goals, and other desired metrics. Nurses and other health professionals with specializations and/or interest in the condition, disease, or the selected issue are your target
      • Questions to Consider

        As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.
        SHOW LESS
        Reflect on quality improvement (QI) initiatives in your workplace:

    • What makes a QI initiative a success? What elements must be incorporated?
    • What opportunities are there for interprofessional collaboration on a QI initiative in your workplace?
    • Proficiency in interpretation of data is critical to understanding and communicating QI outcome measures. What can be done to improve data literacy across interprofessional teams?
  • Resources
  • Suggested Resources
    The resources provided here are optional. You may use other resources of your choice to prepare for this assessment; however, you will need to ensure that they are appropriate, credible, and valid. The Nursing Masters (MSN) Research Guide can help direct your research, and the Supplemental Resources and Research Resources, both linked from the left navigation menu in your courseroom, provide additional resources to help support you.
    Adverse Events and Reporting
    These resources explore how cultures focused on safety learn from adverse events.

    • Rafter, N., Hickey, A., Condell, S., Conroy, R., O’Connor, P., Vaughan, D., & Williams, D. (2014). Adverse events in healthcare: Learning from mistakes. QJM: Monthly Journal of the Association of Physicians, 108(4), 273– Retrieved from https://academic.oup.com/qjmed/article-lookup/doi/10.1093/qjmed/hcu145
    • Skinner, L., Tripp, T. R., Scouler, D., & Pechacek, J. M. (2015). Partnerships with aviation: Promoting a culture of safety in health care. Creative Nursing; Minneapolis, 21(3), 179–185.
  • The following resources explore the benefits and challenges of incident reporting systems.
    • Harrison, R., Lawton, R., & Stewart, K. (2014). Doctors’ experiences of adverse events in secondary care: The professional and personal impact. Clinical Medicine, 14(6), 585–590.
    • Crane, S., Sloane, P. D., Elder, N., Cohen, L., Laughtenschlaeger, N., Walsh, K., & Zimmerman, S. (2015). Reporting and using near-miss events to improve patient safety in diverse primary care practices: A collaborative approach to learning from our mistakes. Journal of the American Board of Family Medicine, 28(4), 452– Retrieved from http://www.jabfm.org/content/28/4/452
  • This resource examines organizational factors that lead to adverse events and near-miss incidents.
    • Patterson, M. E., & Pace, H. A. (2016) A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists. Journal of Patient Safety, 12(2), 114–117.
  • Reporting Systems
    These resources provide comprehensive event reporting systems data and performance assessment information:

    • The Joint Commission. (2017). National patient safety goals. Retrieved from https://www.jointcommission.org/standards_information/npsgs.aspx
    • S. Food & Drug Administration. (2017). FDA adverse event reporting system (FAERS). Retrieved from http://www.fda.gov/Drugs/InformationOnDrugs/ucm135151.htm
    • Hospital Consumer Assessment of Healthcare Providers and Systems. (2017). CAHPS hospital survey. Retrieved from http://hcahpsonline.org/
  • This resource provides examples of adverse events and near-miss incidents:
    • Agency for Healthcare Research and Quality. (2016). WebM&M cases & commentaries. Retrieved from https://psnet.ahrq.gov/webmm
  • Assessment Instructions

    Preparation
    Prepare a comprehensive analysis on an adverse event or near-miss from your professional nursing experience that you or a peer experienced. Integrate research and data on the event and use as a basis to propose a Quality Improvement (QI) initiative in your current organization.Quality Improvement Initiative Evaluation Essay.
    The numbered points below correspond to grading criteria in the scoring guide. The bullets below each grading criterion further delineate tasks to fulfill the assessment requirements. Be sure that your Adverse Event or Near-miss Analysis addresses all of the content below. You may also want to read the scoring guide to better understand the performance levels that relate to each grading criterion.

    • 1      Analyze the missed steps or protocol deviations related to an adverse event or near miss.
      • Describe how the event resulted from a patient’s medical management rather than from the underlying condition.
      • Identify and evaluate the missed steps or protocol deviations that led to the event.
      • Discuss the extent to which the incident was preventable.
      • Research the impact of the same type of adverse event or near miss in other facilities.
    • 2      Analyze the implications of the adverse event or near miss for all stakeholders.
      • Evaluate both short-term and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community). Analyze how it was managed and who was involved.
      • Analyze the responsibilities and actions of the interprofessional team. Explain what measures should have been taken and identify the responsible parties or roles.Quality Improvement Initiative Evaluation Essay.
      • Describe any change to process or protocol implemented after the incident.
    • 3      Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.
      • Analyze the quality improvement technologies that were put in place to increase patient safety and prevent a repeat of similar events.
      • Determine whether the technologies are being utilized appropriately.
      • Explore how other institutions integrated solutions to prevent these types of events.
    • 4      Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement.
      • Identify the salient data that is associated with the adverse event or near miss that is generated from the facility’s dashboard. (By dashboard, we mean the data that is generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for health care management.)Quality Improvement Initiative Evaluation Essay.
      • Analyze what the relevant metrics show.
      • Explain research or data related to the adverse event or near miss that is available outside of your institution. Compare internal data to external data.
    • 5      Outline a quality improvement initiative to prevent a future adverse event or near miss.
      • Explain how the process or protocol is now managed and monitored in your facility.
      • Evaluate how other institutions addressed similar incidents or events.
      • Analyze QI initiatives developed to prevent similar incidents, and explain why they are successful. Provide evidence of their success.
      • Propose solutions for your selected institution that can be implemented to prevent future adverse events or near-miss incidents.
    • 6      Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
    • 7      Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.
  • Submission Requirements
    • Length of submission: A minimum of five but no more than seven double-spaced, typed pages.
    • Number of references: Cite a minimum of three sources (no older than seven years, unless seminal work) of scholarly or professional evidence that support your evaluation, recommendations, and plans.
    • APA formatting: Resources and citations are formatted according to current APA style and formatting.Quality Improvement Initiative Evaluation Essay.