NURS 8302 Discussion: Identifying Practice Gaps for Quality Improvement ANSWER

Post a brief explanation of how you would identify a quality improvement practice gap in your practice or organization. Describe a potential quality improvement practice gap you might use for your DNP project, and explain why. Then, explain at least two types of tools and/or methods you might use to address this quality improvement practice gap, and explain why. Be specific and provide examples.

Sample Answer for NURS 8302 Discussion: Identifying Practice Gaps for Quality Improvement ANSWER

Quality practice gaps in an outpatient setting can be identified from a variety of sources.  Much of the data utilized for quality improvement practice purpose in my organization comes from EHR software, quality measurement tools such as Tableau, patient satisfaction surveys, and from the annual employee engagement surveys.  In the ambulatory setting, many quality indicators like patient falls, depression and violence screenings, pain assessments, risk assessments (BMI & hypertension) can be assessed through the EHR.  This retrospective data collection is utilized by many data collection projects including several national quality improvement database projects (Nash et al., 2019).  As a nurse manager, I have access to reporting analytics that determine the percent of compliance to these quality indicators.  Additionally, my organization utilizes a program called Tableau that also analyzes date from each clinical site in comparison with the organizational standards to produce a weekly report identifying strengths and weaknesses in the organizational quality indicators.  Another resource for identifying quality practice gaps in with our annual employee engagement survey which includes questions about culture of safety, morale, and work-life balance.  Utilizing the data from the various tools provided by my organization allows for in-depth data analysis for identifying practice gaps.

Potential Quality Improvement Gap

A quality improvement gap that has been identified at my organization is access to care.  Access to care is a critical component in providing quality care in that lack of access delays care and preventable services, excessive financial burdens, and increased hospitalizations or length of stays (“Measures Management System”, 2021).  My organization focuses on a 14-day access new patients quality measure, in which all new patient referrals should be scheduled with an appointment within 14 days. This quality indicator has been attainable for all but one provider in our clinic, with current new patient access running about 16-20 days. Provider clinic schedule changes could be made to help alleviate this burden with results tracked using a run chart to help identify improvement or setbacks, as well as the ability to annotate changes along the way

Access of care is also currently affecting my organization in another way.  Due to our extensive Covid surge taking place in our state currently, my organization’s children’s hospital is at 110% capacity with backup in the pediatric emergency department, which has led to several diverting emergency patients at several different instances.  Being one of just a few children’s hospitals in the state and the only one taking care of most of the central and eastern areas of the state, this has been a critical emergent crisis for our area.  The lack of pediatric inpatient beds affects many patients who require frequently scheduled hospitalizations, such as our scheduled admits for pediatric chemotherapy patients.  To help offset this crisis, I have been asked to assist in leading the creation of a new monoclonal antibody infusion clinic for pediatrics age 12-17 years.  This emergency request for assistance to relieve inpatient volumes was announced two days ago with a one-week deadline to open to the new clinic and is hopeful to help alleviate the strain currently being faced by the overwhelming number of pediatric Covid patients.  This will be the only pediatric monoclonal antibody infusion site in the state of Kentucky. This quality improvement gap was identified quickly, and data will be analyzed throughout the development process.

References:

Measures Management System. Cms.gov. (2021). Retrieved 17 September 2021, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Access-Measures.pdf.

Nash, D., Joshi, M., Ransom, E., & Ransom, S. (2019). The Healthcare Quality Book: Vision, Strategy, and Tools (4th ed.). Healthcare Administration Press.

Sample Answer 2 for NURS 8302 Discussion: Identifying Practice Gaps for Quality Improvement ANSWER

The methodology I would utilize to identify a quality improvement gap in my current organization is the hospitals’ scorecard on Hospital Compare.  “The Centers for Medicare & Medicaid Services (CMS), the federal agency that runs the Medicare program, created this tool in collaboration with organizations representing people with Medicare, hospice organizations, other stakeholders, and other federal agencies”. (Center for Medicare and Medicaid Services, n. d.).  CMS’s website, hospital compare, is a website that allows participants/caregivers/others, to identify providers based on the criteria most relevant to them.  In reviewing my current organizations’ scorecard via hospital compare, the hospitals’ rate for 30- day inpatient psychiatric readmissions is 21.1%, while the national average is 20.1, which is not statistically significant.  However, the percentage of patients included in this data (Medicare only), are minimal, compared to the total number of patients discharged from the inpatient psychiatric unit.

To be sure that this data was accurate, I compared this data to the same statistics reported by some of our other payors via the Value-Based Purchasing (VBP) program. This is a method of provider payments, directly related to the providers’ performance.  More specifically, providers are held accountable for the quality of care they provide, which is directly related to the organizations’ reimbursement (HealthCare.gov, n. d.).  My organization currently has VBP agreements with two payors.  As reported by these payors, our 30-day readmission rate for the inpatient psych unit is significantly higher than the local/state/national average.  Thus, this is an opportunity for our department to address.

The method I would choose to address this gap in practice is a retrospective chart review. This is a review of a medical record after a patient has been discharged from the hospital.  It is the most comprehensive method of data collection related to patient care.  Additionally, a retrospective chart review “is the primary tool for answering the “why” of a given situation” (Nash, Joshi, Ransom, E. & Ransom, S., 2019, pg. 114).  Following a patients’ discharge, a thorough review of a patients’ chart could help to provide some detail regarding the patients’ discharge plan, wrap-around services in the community and other factors, or lack thereof, that may have contributed to the patients’ readmission.

After a thorough review of a sampling of patients’ charts, collecting data, I would use a fishbone diagram to assist in sorting the data, identifying potential causes for patients’ readmissions.  The fishbone diagram organizes possible causes, in a format that’s visual for ease in understanding (Nash et al., 2019).  Although the reasons for readmission may be very individualized, my goal would be to ensure that, as an organization, we provided patients with all of the tools required to be successfully discharged to the community. Overall, in a review of this data, the focus would be on psychiatric readmissions, but would also consider patient outcomes.  “Management strategies to reduce readmissions may influence indicators of well-being such as psychiatric symptomatology, functional status, quality of life, social adjustment, self-efficacy, service satisfaction, life skills, medication adherence, and ability to live independently” (RTI-UNC Evidence-based Practice Center, 2015, pg. 25).  Improved quality of life is a goal for patients with severe and persistent mental illness.

References

Center for Medicare and Medicaid Services (n. d.).  Hospital Compare. https://www.medicare.gov/care-compare/resources/about-this-tool

HealthCare.gov (n. d.).  Value-Based Purchasing.  https://www.healthcare.gov/glossary/value-based-purchasing-vbp/

Nash, D. B., Joshi, M. S., Ransom, E. R., & Ransom, S. B. (Eds.), (2019).  The healthcare quality book: Vision, strategy, and tools (4^th ed.). Health Administration Press.

RTI-UNC Evidence-based Practice Center (2015). Effective health care program: Management strategies to reduce psychiatric readmissions. Technical Brief Number 21. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/psychiatric-readmissions_technical-brief.pdf

Sample Answer 3 for NURS 8302 Discussion: Identifying Practice Gaps for Quality Improvement ANSWER

This is an outstanding work Andretta. The methodologies of identifying quality improvement gap in health care organization have been clearly identified. I concur with your post. Ideally, identification of quality improvement gap should be followed by addressing the gap and determination of quality of the service. However, evaluating the perceptions and expectations of patients concerning health care delivery and areas that need improvement remains a great challenge (Javed & Ilyas, 2018). Usually, surveys have been used to understand quality improvement gaps from the perspective of the patients and other stakeholders. However, another important methodology that organizations and providers can use is to compare the perceived and the expected quality of service and identify the gaps between them, utilize the feedback from the stakeholders to enhance quality, and evaluate the real experiences of health care (Lu et al., 2020). As service quality is increasingly becoming a critical aspect of corporate strategy in health care system, an approach of measuring the perception and understanding the gap between perception and expectation can be important in quality improvement initiatives (Dopeykar et al., 2018).

References

Dopeykar, N., Bahadori, M., Mehdizadeh, P., Ravangard, R., Salesi, M., & Hosseini, S. M. (2018). Assessing the quality of dental services using SERVQUAL model. Dental Research Journal, 15(6), 430. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6243813/

Javed, S. A., & Ilyas, F. (2018). Service quality and satisfaction in healthcare sector of Pakistan—the patients’ expectations. International journal of health care quality assurance. https://doi.org/10.1108/IJHCQA-08-2016-0110

Lu, S. J., Kao, H. O., Chang, B. L., Gong, S. I., Liu, S. M., Ku, S. C., & Jerng, J. S. (2020). Identification of quality gaps in healthcare services using the SERVQUAL instrument and importance-performance analysis in medical intensive care: a prospective study at a medical center in Taiwan. BMC Health Services Research, 20(1), 1-11. https://doi.org/10.1186/s12913-020-05764-8

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Sample Answer 4 for NURS 8302 Discussion: Identifying Practice Gaps for Quality Improvement ANSWER

A standard quality improvement tool used to identify gaps in services or within a program of services is the gap analysis.  The gap analysis incorporates a visual of what is desired versus the current status by answering the question of where we are now. Where do we want to be, and what do we propose to close the gap? I have chosen the gap analysis to identify a quality improvement gap within our organization of the lack of palliative and hospice service use early in the disease process.

Research has established a connection with palliative care early intervention to produce a better quality of life for those facing advanced disease processes. However, barriers to earlier access to palliative care remain, which might be attributable to the global lack of awareness of palliative care and the prevalence of negative perceptions and attitudes (Collins et al., 2018). Early palliative care is purported to improve quality of life, avoid unnecessary acute care use, and thus reduce health system costs(Seow et al., 2021). Palliative care may be helpful at any point in the disease trajectory and could be especially valuable soon after a person is diagnosed with a severe illness (IOM, 2015; NASEM, 2022; National Consensus Project for Quality Palliative Care, 2018).

I have identified two tools to address this quality improvement project: the Plan-Do-Check-Act (PDCA) Plan and the Matrix. The PDCA delivers guidelines for an action plan to test by first placing the theory into action by collecting data, checking the data strengths and weaknesses based on objective criteria, and acting by adopting, adapting, or abandoning the improvement theory. The Matrix shows a relation between categories (barriers) and can be used to identify themes such as workforce Core Competencies and prioritize workforce development needs to fill competency gaps(CMS, 2021). The measurable efforts of quality improvement should characterize change in the desired direction, contribute to various parts of the system, and progress toward acceptable outcomes.  Quality Improvement should reflect good-quality practice through research.

CMS Innovation Center 2021 strategy refresh, strategic direction: https://innovation.cms.gov/strategic-directionLinks to an external site.

Seow H, Sutradhar R, Burge F, et al., (2021). End-of-life outcomes with or without early palliative care: a propensity score-matched, population-based cancer cohort study

BMJ Open ;11:e041432. doi: 10.1136/bmjopen-2020-041432

Allemang, B., Patton, M., Greer, K. et al,(2023). Development of the Strengths, Skills, and Goals Matrix: a tool for facilitating strengths-based adolescent and young adult engagement in research. Res Involv Engagem 9, 89. https://doi.org/10.1186/s40900-023-00502-w

Sample Answer 5 for NURS 8302 Discussion: Identifying Practice Gaps for Quality Improvement ANSWER

Practice gaps are the differences that exist between the current state of practice and its intended state. Practice gaps are a helpful tool for identifying issues in the workplace, mainly when performance is falling short of expectations in a healthcare environment (Flodgren et al., 2019). To ensure that the current state of healthcare practice meets or surpasses the expected practice, quality improvement projects can be constructed upon evaluating practice gaps (Robinson et al., 2020). Since they support advancements in critical areas of healthcare practice, like knowledge, skills, and practice, evaluating practice gaps and the ensuing quality improvement initiatives are crucial (Joshi et al., 2018).

Explanation of  How I Would Identify Improvement Practice Gap in My Practice Organization

Practice gaps, as previously stated, represent the discrepancy between what is occurring in practice at the moment and what evidence-based practices recommend should be occurring (Flodgren et al., 2019). Finding practice gaps is a crucial first step toward improving healthcare since it serves as the basis for initiatives aimed at improving quality. Gap analysis is one method of detecting practice gaps. To determine where the deviation is, a gap analysis evaluates current processes and compares them to best practices. A gap analysis describes the discrepancy between what is occurring and what ought to occur, which helps identify a practice gap (Joshi et al., 2018). Utilizing data and research findings is another method for identifying gaps in practice. By comparing best practices with existing practices, one can better discover practice gaps by understanding best practices, which is made possible by research findings (Michel et al., 2019). Among other sources, quality improvement statistics, literature reviews on a range of subjects, national clinical recommendations, patient care audits, and current healthcare trends can all be used to identify research findings (Joshi et al., 2018). A variety of data and information sources, including expert and faculty feedback, participant feedback (including needs assessment results and past CME evaluations), and participant feedback, can also be used to guide the comparison of current practice with best practice to identify practice gaps (Robinson et al., 2020). Practice gaps can also be found through data from the several regulatory agencies that oversee different professions. Understanding how current practice differs from best practice and identifying practice gaps might result from knowledge gathered from pertinent boards and state requirements (Michel et al., 2019).

Potential Quality Improvement Practice Gap that Can Be Use for My DNP Project

Medication administration errors are one possible quality improvement practice gap I might employ for my DNP project. By guaranteeing that healthcare services are safe, effective, timely, equitable, efficient, and patient-centered, a quality improvement project to reduce pharmaceutical errors would improve patient outcomes (Hammoudi et al., 2018). The complexity of pharmaceutical safety is the rationale behind the decision to address this practice gap. Medication prescription and administration are intricate procedures with many potential for error. Medication errors are not only quite likely to occur but also harm patients’ health and general well-being. Therefore, it is imperative to develop a less error-prone system to guarantee that the appropriate drugs are administered to the appropriate patients at the appropriate time (Hammoudi et al., 2018). In addition to improving patient outcomes, this would promote patients’ safety, health, and general well-being. The five rights of medicine administration—the appropriate patient, the proper medication, the right time, the proper dosage, and the correct route—can all lead to pharmaceutical errors (Hammoudi et al., 2018). However, there are times when more than one person ensures these five rights are upheld. Various healthcare experts must be involved in prescribing and administering medications (Jember et al., 2018). System modifications are required to guarantee that the five rights are upheld during the prescription and administration of drugs. It is imperative to address systemic problems, such as system misconfiguration, diversions, lengthy processes, and inadequate training of healthcare staff, that may lead to prescription errors. The quality improvement project aims to develop a pharmaceutical error prevention, mitigation, and reduction system that improves patient safety and healthcare outcomes (Hammoudi et al., 2018).

Two Types of Tools/Methods that I Might Use to Address Quality Improvement Practice Gap

The Plan-Do-Study-Act (PDSA) paradigm can be used in quality improvement projects and research endeavors that seek to positively impact healthcare procedures to achieve desired results. The Institute for Healthcare Improvement has made extensive use of this technique for quick cycle improvement (Joshi et al., 2018). The cyclical nature of affecting and evaluating change is one of this model’s distinctive aspects results (Christoff, 2018). Quality improvement projects are thoroughly vetted to ensure that they achieve the intended goal. It is best achieved by periodic, small-scale PDSAs rather than large, slow ones before system-wide changes are implemented. Establishing a functional or causal relationship between changes in processes (more especially, behaviors and skills) and results is the goal of PDSA quality improvement initiatives. Before applying the PDSA cycles, Langley and colleagues put forward the following three questions:  What is the project’s aim?  How will it be determined if the objective was accomplished? and (3) How will the objective be attained? The first steps in the PDSA cycle are to identify the type and extent of the issue, the changes that may and should be made, the specific change that needs to be planned, the people who should be involved, the things that should be measured to gauge the change’s impact, and the target audience for the strategy. After that, facts and information are gathered and changes are put into practice. Several important metrics that show success or failure are reviewed to evaluate and interpret the implementation study’s results. Finally, the results are put into practice by either starting the process over or executing the modification.

The VA’s National Center for Patient Safety created the health failure modes and effects analysis (HFMEA) tool for risk assessment. In HFMEA, there are five steps: first, establish the topic; second, put together the team; third, create a process map for the topic, numbering each step and substep in turn; and fourth, carry out a hazard analysis (e.g., determine the reason behind failure modes, assign a score to each failure mode using the hazard scoring matrix, and go through the decision tree analysis) formulate plans of action and goals. When performing a hazard analysis, it is crucial to enumerate all probable and actual failure modes for every process, assess if the failure modes call for additional action, and enumerate all causes for each failure mode when it is decided to move forward. Following the hazard analysis, evaluating the necessary steps and result measurements is critical. This includes outlining what will be removed or regulated and assigning accountability for each new action.

Conclusion

Practice gaps denote a difference between what should be happening in practice and what is currently happening (Flodgren et al., 2019) The identification of practice gaps is an essential building block to advance healthcare as it helps form the foundation for quality improvement projects. One way to identify practice gaps is through gap analysis. A gap analysis includes the evaluation of current practices and compares the same to best practices where the deviation is. A gap analysis informs the identification of a practice gap by outlining the difference between what is happening and what should be happening. One potential quality improvement practice gap that I would look to address is medication errors. The prescription and subsequent administration of medication is a complex process with various points of error. In addition to the high risk for errors, the occurrence of medication errors is detrimental to the patients and adversely affects their health and well-being (Hammoudi et al., 2018) As such, it is critical to come up with a system that is less prone to errors to ensure that the right medications are given to the right patients at the right time (Jember et al., 2018).

 

References

Christoff, P. (2018). Running PDSA cycles.Current problems in pediatric and adolescent health care,48(8), 198-201.

Flodgren, G., O’Brien, M. A., Parmelli, E., & Grimshaw, J. M. (2019). Local opinion leaders:effects on professional practice and healthcare outcomes.Cochrane Database of Systematic Reviews, (6).

Hammoudi, B. M., Ismail, S., & Abu Yahya, O. (2018). Factors associated with medication administration errors and why nurses fail to report them.Scandinavian Journal of Caring Sciences,32(3), 1038-1046.

Jember, A., Hailu, M., Messele, A., Demeke, T., & Hassen, M. (2018). The proportion of medication error reporting and associated factors among nurses: a cross-sectional study.BMC Nursing,17(1), 1-8.

Joshi, M., Ransom, E. R., Nash, D. B., & Ransom, S. B. (Eds.). (2014). The healthcare quality book: vision, strategy, and Tools. Chicago, IL, USA:: Health Administration Press.

Michel, J., Chimbindi, N., Mohlakoana, N., Orgill, M., Bärnighausen, T., Obrist, B., … & Tanner, M. (2019). How and why policy-practice gaps come about: a South African Universal Health Coverage context.Journal of Global Health Reports,3, e2019069.

Robinson, T., Bailey, C., Morris, H., Burns, P., Melder, A., Croft, C., … & Teede, H. (2020).Bridging the research-practice gap in healthcare: a rapid review of research translation centers in England and Australia.Health research policy and systems,181-17.

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