20. · Preparation Your executive summary captured the attention
and interest of the executive leadership team, who have asked
you to provide them with a detailed report addressing outcome
measures and performance issues or opportunities, including a
strategy for ensuring that all aspects of patient care are
measured.
·
Note: As you revise your writing, check out the
resources listed on the Writing Center's
Writing Supportpage. 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.
· How might you engage stakeholders to help develop,
implement, and sustain a vision to actually change and improve
patient outcomes?
· What arguments might be most effective in obtaining
agreement and support?
· What recommendations would you make to implement a
proposed plan for change?
· The following resources are required to complete the
assessment.
·
APA Style Paper Tutorial [DOCX]. Use this for your
report.
· Requirements
Note: The requirements outlined below correspond to
the grading criteria in the Outcome Measures, Issues, and
21. Opportunities Scoring Guide. Be sure that your written analysis
addresses each point, at a minimum. You may also want to read
the Outcome Measures, Issues, and Opportunities Scoring Guide
and
Guiding Questions: Outcome Measures, Issues, and
Opportunities [DOCX] to better understand how each criterion
will be assessed. Drafting the Report
· Analyze organizational functions, processes, and behaviors in
high-performing health care organizations or practice settings.
· Determine how organizational functions, processes, and
behaviors affect outcome measures associated with the systemic
problem identified in your gap analysis.
· Identify the quality and safety outcomes and associated
measures relevant to the performance gap you intend to close.
Create a spreadsheet showing the outcome measures.
· Identify performance issues or opportunities associated with
particular organizational functions, processes, and behaviors
and the quality and safety outcomes they affect.
· Outline a strategy, using a selected change model, for ensuring
that all aspects of patient care are measured and that knowledge
is shared with the staff.
· Writing and Supporting Evidence
· Write coherently and with purpose, for a specific audience,
using correct grammar and mechanics.
· Integrate relevant and credible sources of evidence to support
assertions, correctly formatting citations and references using
APA style.
· Additional Requirements Format your document using APA
style.
· Use the
APA Style Paper Tutorial [DOCX]. Be sure to include:
· A title page and reference page. An abstract is not required.
· A running head on all pages.
· Appropriate section headings.
22. · Properly-formatted citations and references.
· Your report should be 6 pages in length,
not including the title page and reference page.
· Add your Quality and Safety Outcomes spreadsheet to your
report as an addendum.
·
Portfolio Prompt: You may choose to save your report
to your
ePortfolio.
·
· RUBRIC Competencies Measured By successfully completing
this assessment, you will demonstrate your proficiency in the
following course competencies and assessment criteria:
· Competency 1: Analyze quality and safety outcomes from an
administrative and systems perspective.
· Identify typical quality and safety outcomes and their
associated measures.
· Competency 3: Determine how specific organizational
functions, policies, processes, procedures, norms, and behaviors
can be used to build reliability and high-performing
organizations.
· Analyze organizational functions, processes, and behaviors in
high-performing organizations.
· Determine how organizational functions, processes, and
behaviors support and affect outcome measures for an
organization.
· Identify performance issues or opportunities associated with
particular organizational functions, processes, and behaviors
and the quality and safety outcomes they affect.
· Competency 4: Synthesize the various aspects of the nurse
leader's role in developing, promoting, and sustaining a culture
of quality and safety.
· Outline a strategy for ensuring that all aspects of patient care
23. are measured and that knowledge is shared with the staff.
· Competency 5: Communicate effectively with diverse
audiences, in an appropriate form and style, consistent with
applicable organizational, professional, and scholarly standards.
· Write coherently and with purpose, for a specific audience,
using correct grammar and mechanics.
· Integrate relevant and credible sources of evidence to support
assertions, correctly formatting citations and references using
APA style.
·
Running head: OUTCOMES, ISSUES, AND OPPORTUNITIES
1
Outcomes Measures, Issues, and Opportunities
Kathryn Forsyth
Capella University
HealthCare Quality Safety Management
Outcome Measures, Issues, and Opportunities
July, 2020
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Outcome Measures, Issues, and Opportunities
24. Medication administration is a large part of care provided to
patients during each shift.
Nurses must deal with multitasking, interruptions, chaotic
environments, and maintain
professional quality care. The United States has between 7,000
and 9,000 medication error
related deaths each year (Tarig, Vashisht, & Scherback, 2020).
Near misses and adverse events
can occur during any point during the medication process from
orders, documenting,
transcribing, dispensing, administering, and/or monitoring
(Tarig, 2020). Nurses have high
patient loads, increased responsibilities, need to be aware of
health costs and ways to decrease
those costs. This report will address measurable patient
outcomes, gaps that need to be addressed
and interventions that are available to improve patient safety.
The Agency for Healthcare Research and Quality (AHRQ) has
defined patient safety as
“freedom from accidental or preventable injuries produced by
medical error” (Agency for
Healthcare Research and Quality (AHRQ), N.D.). A Quality
Interagency Coordination Task
Force was created by the Department of Health and Human
25. Services and other federal agencies
has advised using teamwork is an important way to improve
patient safety (Buljac-Samardzic,
Dekker-van Doorn, & Maynard, 2018). This interagency team
provided an increased awareness
to the media which put a spotlight on an issue that many would
have rather ignored. The group
has pushed to increase reporting of all adverse medical events
(ADEs). By exposing the issues,
the agency has forced facilities to create new policies and
procedures to reduce adverse events.
High-Performing Organizations
Doctors Hospital is a high performing facility with many awards
for providing the best
care. This organization has a culture to encourage the staff
communicate when they have an
opinion on a way to improve patient care. The administration
and leaders use the Triple Aim
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Framework to evaluate the root cause of medication errors
within the facility. The goal of Triple
26. Aim is to provide interventions to improve quality of
healthcare. The interventions and goals are
used to improve patient outcomes, patient satisfaction, decrease
errors, and reduce cost of
healthcare (American Hospital Association, 2015).
Initiatives focusing on patient-centered quality provides an
analysis of the issues and how
to become a High Reliability organization and implement the
Triple Aim framework. Both high
reliability and Triple Aim focuses on quality improvement
initiatives to reduce and/or prevent
patient injury and improve safety. When using High Reliability
and Triple Aim framework, the
facility is seeing quality interventions with improved patient
outcomes, patient satisfaction, a
decline mortality rates, adverse events, and near misses
(Bodenheimer & Sinsky, 2014). The use
of technology, specifically bar code scanning has decreased
medication errors however the use of
technology should never replace nurses knowledge, competency,
continued use of double
checking information for high risk medications and using the
computer as the third check to
completed the triple check system. By encouraging a
27. questioning attitude, the facility is
encouraging nurse to seek additional information on unfamiliar
drugs and asking questions for
when the medication orders does not make sense for the
patient’s diagnosis (Rodziewicz &
Hipskind, 2020). The implementation of the above initiatives
has reduced the medication errors,
improved communication, and increased patient education on
medications.
Doctors Hospital is working to address medication errors after
each event is report.
Trying to address adverse events and near misses as a systemic
approach is very difficult as there
are many different units in the facility and each unit high risk
medications are not the same.
Nursing leaders encouraging self-reporting of adverse events or
near misses has improved
communication between administration, leaders, and other staff.
The use of non-punitive or
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retribution when reporting medication errors or concerns has
built trust between all parties.
28. Leadership using medication errors as a learning opportunity
instead of placing blame, will
increase the overall quality of care. Determining the root cause
of the medication error to create
interventions to prevent the same error in the future is critical.
Doctors Hospital received a grade
of “c” in 2017, in 2018 the grade was a “d”, and in 2019 the
grade was a “b”. Per the Leapfrog
Group 2020 website, the issues with medication and patient
safety are related to communication
about medications, discharge planning, and staff
communication. Leapfrog automatically gives
the facility a 100 is they are using the barcode system, which is
not indicative of adverse events
and near misses since this is int addressed. In 2018, the hospital
developed initiatives, objectives,
and goals to improve their rating. The new score is now a “b” in
2020 which is attributed to
improved training, improved technology, encouraging
expressing concerns and adverse events,
and creating multidisciplinary group to improve communication.
Outcomes Measured
Doctors hospital mission and vision include a commitment to
29. the care and improvement
of human life. To strive to deliver high quality, cost effective
healthcare by incorporating the
following value statements, to recognize the unique and
intrinsic worth of each individual, to
treat everyone with compassion and kindness, act with absolute
honesty, integrity and fairness in
our business and personal lives. Also, our colleagues are
valuable members of our healthcare
team and vow to treat each other with loyalty, respect, and
dignity (Doctors Hospital, 2020).
Leadership skills, communication, and trust is an integral part
of change, the leader must
be able to lead, deal with conflict, inspire, and communicate
effectively. The interventions,
objectives and goals must be clearly stated and defined for the
staff so there is no
misunderstanding. Outcomes and culture are positively
connected to leadership atmosphere and
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staff satisfaction with their jobs. Experienced staff that have
been with the same facility for many
30. years has experienced changes in policies and procedures, shifts
in vision and mission
statements, working through nursing shortages and improvement
of quality measures. The lack
of leadership will lead to increase in stress in the work
environment, increases the rate of failures
for new interventions, policies, procedures, and outcomes.
Highly motivated leadership can
improve the work environment, increase adherence to new
policies, procedures and intervention
therefore encouraging the staff to meet objectives and goals of
the project.
Adding technology to include bar scanning, smart pumps,
ability to research medication
at bedside to provide education and addressing look alike,
sound alike drugs have decreased
adverse events and near misses. By adding technology, the
facility has enabled the nurses to
provide a third check to use of medication which increases
patient safety and quality of care. By
using High Reliability, we can focus on key elements to include
providing better education to
staff, increase training for leadership, encourage a culture
focused on safety and reduction of
31. medical errors (Chassin & Loeb, 2013).
Performance Issues and Opportunities
Medication errors are extremely costly for the organization and
insurance carriers.
Almost 400,000 a year hospitalized patient has experienced
preventable harm of some type. This
has resulted in approximately 100,000 deaths each year. This
creates an extreme financial burden
that can cost up to $20 billion dollars. Errors may contribute to
the death of a patient or cause
long term harm which can lead legal issues that will increase
costs to the facility (Rodziewicz &
Hipskind, 2020).
Many errors are related to look alike, sound alike drugs, which
is being dealt with by
each facility as well as drug companies. Facilities are
encouraging staff to report these types of
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medications so the facility can come up with a plan to address
the drugs and ways to differentiate
32. between them. One suggestion for drug manufactures is to use
Tall Man lettering and color-
coding which aims to highlight the difference between two
similar drugs by capitalizing part of
the drug names. Many organizations have endorsed Tall Man
lettering including the Joint
Commission and the Institute for Safe Medication Practices
(ISMP) (Larmené-Beld, Alting, &
Taxis, 2018). By encouraging voluntary reporting in a
blameless, guiltless environment will lead
the facility to be able to investigate and determine the core
issue and develop ways to prevent the
error in the future (Patient Safety Network, 2019).
After researching 2019 medication errors, the evidence shows
there is an overwhelming
incorrect usage of the bar code scanning, only 30% of staff was
using the system correctly.
Personally, I have scanned the bar code from the chart which
led to making a medication error by
scanning the wrong bar code and giving the medication to the
wrong patient. There are many
ways to override the system when alerts pop up, many nurses do
not even read the alerts. One
way to address this is update the bar code system for the nurse
33. to have to manually type a reason
why the alert is being overridden. This will impact time but will
overall make the nurse more
accountable. Total numbers of errors on the 50 bed burn unit for
2019 was 6000. Total resulting
in injury was 600 and total deaths 15. In 2019, the average
number of medical errors on the 50-
bed unit was sixteen per day, this seems high, however
medication errors include the route,
dosage, time, patient, and medication. So many of these errors
could be related to time and most
errors did not cause injury or death. The attached spreadsheet
breaks down the errors in 2019 and
2020 by total errors per year, total errors resulting in injury,
total errors resulting in death, and
correct use of bar code scanning.
Strategy Outline
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Nursing leadership plays a key role in implementation of
change, encouraging quality
communication, and improving patient outcomes. Lack of strong
34. leaders will ultimately lead to
failure of the initiative, objectives, and goals of the project.
Barriers may inadvertently be placed
by administration, leadership, and other staff which may limit
the nurse being able to provide
quality, cost efficient, safe care. Forces that can drive change in
healthcare include cost, need of
specific treatments, high patient to staff ratios, ethics, values,
code of conduct, and the drive to
improve patient outcomes and satisfaction (Salmond &
Echevarria 2017). Use of change theory
for this report is useful as without a structured approach the
initiatives and goals will fail.
Change theory includes Mr. Lewin’s use of unfreezing, moving,
and refreezing. Unfreezing is to
identify the issues and assess need for change. Moving is the
interventions needed for a plan to
be created and put into effect. Refreezing the plan is in place,
the changes have been made and a
new normal is established (Cummings, Bridgman, & Brown,
2016).
Leading change is a challenge for leaders with the intricacies
and challenges of ever-
changing health care environments to ensure quality patient
35. care. Rogers’ Innovation Diffusion
Theory includes five stages include knowledge, persuasion,
decision, implementation, and
confirmation (Udod & Wagner, 2018). Leaders using the change
theory and the five steps of
Rogers’ theory will be able to ignite change, address strengths
and weaknesses of the team,
encourage the team to incorporate interventions to achieve the
goals. Leaders need to be able to
adapt and use multiple types of leadership theories, have
excellent listening skills, and create a
welcoming environment to encourage open, honest
communication, and defuse conflict.
For this project I believe I would use Rogers’ Innovation
Diffusion Theory, the first stage
is knowledge, implementing new education on technology, the
need for the change, and the
initiatives, objectives and goals would be reviewed. This would
encourage everyone to be ready
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for the change. The leaders would want to address the strengths
and weakness of the staff, by
36. determining the staff that area already using the bar code
system correctly so they can pair up
others who are not for mentoring. The idea would be to use the
strength of some to overcome the
weakness of others with mentoring, peer reviews, and
encouragement, this would be part of the
persuasion step. The third step is the decision, which is when
the interventions are decided upon,
when the project will start. Fourth step is to implement the
interventions and lastly would be to
confirm the interventions are moving the staff towards the goals
set.
By implementing additional teaching on use of bar scanning
system, updating the
technology to force the nurse to address the reason when the
system alerts, adding triple checks
to high risk medications, encouraging nurses use Wi-Fi to
address any medication they need
education on and provide that education to the patient and
reporting of look alike, sound alike
drugs so the pharmacist can tag those drugs with an additional
alert. By implementing these
initiatives, the 2020 data shows a 50% reduction in medication
errors, errors resulting in injury
37. are down 66%, injury resulting in death is down 66% and
correct use of bar code scanning has
improved by 60%. Please see attached spreadsheet to review the
past six months and see how the
initiatives implemented has reduced errors per month.
Proposed plans will be shared with all stakeholders either in a
staff meeting or
electronically. During the group presentation, the need for
change will be addressed,
interventions, objectives, and goals will be shared. Everyone
present will be given an opportunity
to review the written material, ask questions and express
concerns or ideas.
Conclusion
Medication errors have always been an area we can all improve
on, use of technology
with bar code scanning, smart pumps, and the ability to research
drug information at the bedside
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has reduced errors. Healthcare is an ever-changing environment;
we must learn to change and
38. initiate policies and procedure to improve patient safety.
Striving to reduce near misses and
adverse events will be a goal for every facility. We must work
together to improve safety and
patient outcomes by being more diligent when administering
medications.
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References
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