ECO 605 Discussion 5.2: Structure—Process—Outcome Approach
Discussion 5.2: Structure—Process—Outcome Approach
The intensive care unit I work in established a diabetic ketoacidosis (DKA) treatment protocol.
Structure refers to the resources used including staff, equipment, and the facility (Hicks, 2021). For structure, this particular ICU has four different intensivists, six respiratory therapists, and about two dozen staff nurses. Each room has a minimum of six IV pumps.
Process refers to the activities involved in providing care (Hicks, 2021). The intensivists will start with diagnosing the patients with DKA and initiate the DKA protocol. Once a patient is diagnosed with DKA, the patient becomes an “ICU” level status. A nurse is only allowed to care for two ICU level patients. The respiratory therapists will take arterial blood gas measurement and ensure the patient’s airway is adequate. The nurses will initiate IV access, draw labs, and gather all necessary equipment needed to treat the DKA patient. With this new protocol, once the labs are received, the nurse will initiate an IV insulin drip at the protocol’s prescribed rate and replace any electrolytes as needed.
With outcome, this involves the consequences of care (Hicks, 2021). This protocol emphasizes the importance of electrolyte balance in patients with DKA and has nurses replacing them constantly since DKA patients are prone to be dehydrated and have electrolyte imbalances. Another outcome of this DKA protocol is to have the patient’s blood glucose decrease at a safe rate until it is under 180mg/dL.
References
Hicks, L. L. (2021). Economics of Health and Medical Care. Jones & Bartlett Learning.
A quality improvement plan I have been a part of in the past is reducing hospital-acquired pressure injuries (HAPIs). These ulcers are common in the hospital and completely avoidable with the proper interventions. Using the Structure/Process/ Outcome model and two examples of each step for ways in which HAPIs can be reduced will be examined.
Structure can be viewed as the inputs or resources utilized to provide patient care (Hicks, 2021). For HAPIs this would be the number of nurses and support staff involved in patient care and the proper education on how to reduce HAPIs. Ensuring that patients are moved from each position at the proper interval requires the necessary staff to perform such activities. Reviewing the workload and staff on each shift is crucial to meet a staffing metric that allows for HAPI reducing interventions. If nurses need to change dressings, remove, or shift equipment and implement device use, then time for these actions needs to be allocated (Cooper et al., 2020). Education and utilizing best practices is another element that needs to be considered in this quality improvement plan. Nurses and other staff members need to be educated not only on preventative interventions of HAPIs, but also the primary causes. This education will take need to be completed on a rolling basis. New interventions are being used each day and an MSN nurse educator will have to be hired and help to disseminate information to staff.
Process is the second step in this quality improvement model which has to do with policy and procedure (Hicks, 2021). What exactly are the policies that dictate the proper procedure for reducing HAPIs? How often are patients being moved off bony prominences?
What happens if initial interventions are unsuccessful? Which model of care is the best approach to this improvement project? A multi-interventional approach has been shown to greatly reduce the pressure put on the area and reduce tissue breakdown (Gaspar et al., 2019). On the unit I worked on, each room had a turn clock with the name of the nurse responsible was at each two-hour interval. A signature was required to be next to the name after the turn was completed. The policy was that each at risk patient have this intervention and of breakdown was detected additional measures such as compression stockings and pressure-free mattress use would be implemented (Cooper et al., 2020). This was a standard operative procedure or (SOP) for these patients. The model of care delivery that is best suited to reducing HAPIs is the team model of nursing. This multifaceted approach allows for collaboration across the care team. Nutrition, ambulation, and unlicensed support staff members are vital to the success of reducing HAPIs (Gaspar et al., 2019). Utilizing a team approach reduces the workload and the burden of care on the nurse which allows for better patient outcomes.
Outcomes is the last element in this quality improvement strategy (Hicks, 2021). The cost of a HAPI is that the hospital or facility is not reimbursed for care during that stay. This has a considerable impact on the bottom line for that facility (Cooper et al., 2020). The investment of the initial program also impacted our facility, but not as severely as receiving a zero payment for a lengthy hospital stay with multiple disciplines utilized. This opportunity would provide the foundation for a future reduction in liability for the facility as HAPIs cost several billion dollars annually to the healthcare system (Cooper et al., 2020). We were able to add a nurse educator and invest in continuing education materials and reduce the HAPI rate on the floor by 12%. The consequence of HAPIs involves patient outcomes. Is the number of patients who acquire pressure ulcers comparable to other facilities utilizing similar interventions? Adding in enhanced quality measures can improve outcomes and help patients improve their quality of life (Gaspar et al., 2019). This can also contribute to a reduced 30-day readmission rate which also impacts the cost to the facility. Increased costs from preventable injuries can greatly reduce the reimbursements a facility receives, which can impact staffing, services offered, and the populations served. Similarly, patients who receive substandard care will suffer worse outcomes and be less likely to return for additional treatment.
Cooper, K. D., McQueen, K. M., Halm, M. A., & Flayter, R. (2020). Prevention and treatment of device-related hospital-acquired pressure injuries. American Journal of Critical Care, 29(2), 150-154.
Gaspar, S., Peralta, M., Marques, A., Budri, A., & Gaspar de Matos, M. (2019). Effectiveness on hospital‐acquired pressure ulcers prevention: a systematic review. International wound journal, 16(5), 1087-1102.
Hicks, L. (2021). Economics of health and medical care. Jones & Bartlett Publishers.
Initial Post: Identify a health service quality improvement that you have been involved in or would like to see implemented.
- Advance Directives is a health service quality improvement example where there is involvement and needs that exist requiring further implementation in hospital due to patient and family’s knowledge deficits, knowledge with no execution, and execution without availability. Any of these result in delay in care.
Refer to the Structure/Process/Outcome approach to quality improvement. Identify two structures, two approaches, and two outcomes for your selected quality improvement.
Referring to both Donabedian’s Function/Structure/Outcome strategy, The Nursing Role Effectiveness Model by Irvine, Sidani and McGillis, along with Pringle and Doran’s variables to the model that recognizes components for positive patient outcomes, below are two of each variable to approach this quality improvement initiative, (Waxman, p 201-224). These are meant to standardize information for higher quality healthcare, (VanDeVelde-Coke, 2012)
- Structures: nurses with advanced education and the organization staffing mixture
- Approaches: interdependent roles of case/care management and medical care-related activities with expanded scope of advanced nursing clinical practice.
- Outcomes: Functional health outcomes with status and knowledge of disease, treatment of management with the prevention of complications.
Waxman, K.T. (2018). Financial and business management for the doctor of nursing practice (2nd ed.). Springer Publishing Company. ISBN 13: 9780826122063
VanDeVelde-Coke, Susan & Doran, Diane & Grinspun, Doris & Hayes, Laureen & Boal, Anne & Velji, Karima & White, Peggy & Bajnok, Irmajean & Hannah, Kathryn. (2012). Measuring outcomes of nursing care, improving the health of Canadians: NNQR (C), C-HOBIC and NQuiRE. Nursing leadership (Toronto, Ont.). 25. 26-37. 10.12927/cjnl.2012.22959.
When I was at Loyola University for my BSN, I did a presentation on quality improvement and my example of quality improvement in healthcare was a plan to reduce postoperative infections. One structure in this health service quality improvement is the number of nurses and healthcare providers involved not only in the surgery but post surgery. The more staffing there is, the higher the chance of everyone doing quality work and focusing on what they need to in order to not spread infections. The next structure is the experience and education of the nurses and providers. They need to know about aseptic technique and how to follow it in order to assure that bacteria isn’t spreading in surgery and after surgery. The next aspect we will talk about is approaches in health service quality improvement. An example of an approach may be the model of care delivery. This model will show what each medical professional is responsible for in regard to caring for a patient going into surgery. This may include the physician explaining risks and benefits of procedures and getting consent. Another approach in this quality improvement example is organizational policies and procedures. An example of how this is used in regard to decreasing post-op infections is imagining someone gets a foley inserted due to anesthesia causing bladder retention in surgery. Patients with foley catheters have a risk of getting CAUTI which is catheter associated urinary tract infections. Nurses and doctors must know policies and procedures for maintaining a foley catheter such as how long until it needs to be changed, when the bag for urine should be emptied, how the tubing is supposed to be placed, etc. Lastly, we will talk about the outcomes of this quality improvement example. An example of an outcome is symptom control. If we see that a post-op patient is having trouble urinating, then we should insert a foley in order to remove the urine building up which could cause an infection. Another example of an outcome is patient satisfaction. After a surgery, health professionals must make sure they care for the patient and the patient is satisfied. If the patient starts saying they don’t feel well then it’s the healthcare providers responsible to manage their symptoms and reduce any chance of an infection.