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Discussion 1: Quality and Safety in Healthcare and Nursing Practice

Discussion 1: Quality and Safety in Healthcare and Nursing Practice

Discussion 1: Quality and Safety in Healthcare and Nursing Practice

Previous Experience with Quality and Safety

Improving quality and safety in healthcare are essential. Improving healthcare quality in the STEEP ( Safety, Timely, Effective, Efficient, Equitable, Patient-Centered) focus areas require a change at four different levels. Level A is the patient’s experience. Level B is the microsystem where care is delivered by small provider teams. Level C is the organizational level, the macrosystem, or aggregation of microsystems and supporting functions. Level D is the external environment, including payment mechanisms, policy, and regulatory factors (Nash et al., 2019).

Some of my previous experiences with quality and safety are being an advocate for high risk for falls patients, improving drug-drug- interactions in the units to prevent harm to patients, advocating for transportation issue for outpatients to avoid delay in care services, advocating for diagnostic testing, and medications coverage with patients’ health insurance, advocating for telehealth implementation for my department to prevent unnecessary exposure for patients at high risk for Covid 19 and patients with lack of transportation issues.

My role as a DNP-prepared nurse in nursing practice and healthcare delivery

As a DNP-prepared nurse, the first thing that I do is identifying the problem. For example, the number of falls on the in-patient side was highly elevated. When determining the cause of falls on the in-patient units, I realized that most falls occurred due to negligence, such as bed rails down; the beds were not at the lowest position. When asked, some patients report falling when they attempted to get up to go to the bathroom independently because the staff was not available when they called. When identifying the cause for falls on the outpatient side, most patients fell due to side effects or drug-drug interactions. There are patient-specific, drug-specific, and clinician-specific risk factors for Adverse Drug Events (ADE). Polypharmacy, taking more medications than clinically necessary, is likely the most substantial risk factor for ADEs. Elderly patients, who take more drugs and are more vulnerable to specific medication adverse effects than younger patients, are particularly vulnerable to ADEs (PSNet, 2019).

After identifying the fall problems and the possible causes, my implementations to improve the number of falls was as follows: For the in-patient unit. I recommended that the staff raise the bed rails when not providing direct care to patients. I verify that all beds are in the lowest position and suggest that the manager ensure that all staff responds promptly to the call light. The patient does not have to be your patient. If you are passing by the room, you hear or see the call light flashing; you should stop and check on the patient to ensure they do not need help. I proposed implementing medication reconciliation at each visit for the outpatient units to ensure that the patients are not on many medications causing falls and verify drug-drug interactions. For example, two months ago, I ordered carbidopa-levodopa for one of my Parkinson’s disease patients. However, when she went to see her primary care, they prescribed lisinopril and amlodipine. The patients’ blood pressure dropped so low that the patient became dizzy and experienced frequent falls. When doing my medications reconciliation, I noticed that she had two new blood pressure medications combined with carbidopa-levodopa. So I held lisinopril and messaged the primary provider care right away.

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After my interventions, I went back to the system where the staff reported adverse events to collect data on falls. The number of falls greatly improved in the in-patient units.  For the outpatient units, family members and patients report significant improvement when interviewing them about frequent falls experiencing at home.

It is very significant to ensure the quality and safety of healthcare delivery in nursing practices. The quality and safety of healthcare delivery determine the effectiveness and success of healthcare. Several factors, such as falls, significantly influence the quality and safety of healthcare delivery in nursing practices. Another factor that influences the quality and safety of healthcare delivery is nurses’ negligence in attending to the patient immediately. There are several cases in which it has been found that a patient with serious health issues does not get the immediate attention of nurses or medical staff, which increases the number of falls and the chance of death of the patient (Trentino et al., 2019). The negligence of the nurses in attending to the patients immediately lead to severe issues. Neglect also affects the perception of the patients about the quality and safety of healthcare delivery.

Discussion 1: Quality and Safety in Healthcare and Nursing Practice References

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

Patient Safety Network ( PSNet) (2019). Medication errors and adverse drug events. https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events

Trentino, K. M., Farmer, S. L., Swain, S. G., Burrows, S. A., Hofmann, A., Ienco, R., … & Towler, S. (2019). Increased hospital costs associated with red blood cell transfusion. Transfusion, 55(5), 1082-1089.

Quality and Safety Measures

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Quality and Safety have been the focus of every Health Care System; the most apparent and visible workload force dynamic programming system. We are responsible for keeping our patients safe and healthy, so that they can continue life as they know it. We are obligated to do our very best for our patients. Our patients also look to us to keep them safe, and to keep them from any further harm and danger. Therefore, we as Health Care Providers  are always trying to improve upon patient’s outcome for their safety, yet we have been falling short the majority of the time to keep this quality and safe care on a higher plane and to maintain that steadfastness.  Sometimes, we failed to even go beyond the plane. Nash and others (2019) discussed this very same poor outcome in our health care system. Nash, et al. (2019) described, in order to succeed in this area of Quality and Safety, we need to focus on a plan; an idea we can follow step by step; something that is measurable and is obtainable. Nash, et al. (2019) described it as the “Blueprint”; the Blueprint is designed to have different functions, yet unchangeable in its format; In other word, the Blueprint is designed to accomplish what it was created to do; the Blueprint itself does not change its form. Nash, et al. (2019) continued on to say a Hammer has many functions, but it remains a Hammer.  A Hammer helps to build a house, and also helps to build a bench. Nash (2019) noted, that the Blueprint and the Hammer are types of quality improvement tools, (Nash, et al., p. 22-23).

The Blueprint or the improvement tools can also refer to best practice tools; tools or best practices that are researched and considered evidence based practice for best outcome; these are best practices that provide the most quality care for our patients. However, we in the Health Care Industry are ineffective or in equipped with most of the best practices evidence based to improve upon patient care. Nash, et al. (2019) and “The Executive Summary”: In Crossing the Quality Chasm (2001, p.g. 08-19) also detailed this endeavor as to why we are not keeping that plane steady and also failing to make further progress with Quality Care and Safety measures. From what I gathered from my reading, the best outcome, comes from when the patient’s needs are identified and the tool or best practice can or should be used to meet these needs. in other words, the tool should not be used to curtail best practice for the patient before addressing first, the patient’s needs. Nash, et al. (2019) stated, we can misuse, under-use and over-use best practice evidence based tools. The goal is to identify the patient’s need, risk factor, (Nursing Diagnoses) for an individual patient. Then functionally use the tool to meet patient’s needs. In order words, according to Nash, et al. (2019),  the tool is designed to carryout many functions, but remains intact; Nash, et al. (2019) gave the example by saying a Hammer carryout many functions, but it remains a Hammer.

In my hospital, we use Hourly Rounds to assist with quality care and safety measures. However, we misuse this by not allowing the tool to function best for the individual patient. We make the tool qualify for all patients. All patients may not have to be turn and reposition, yet we make hourly rounds a function for all patients. Therefore, hourly rounds become a two hour hourly rounds or a three hour hourly rounds. If we focus on the need of the individual patient, then the tool will function effectively as we implement the tool for what we need it to achieve. If the patient is at risk for skin breakdown, then we ought to comply and make sure we are doing those hourly rounds. if the practice is not being carry out or not being implemented in this fashion then Nash, et al. (2019) also described this to be under- use of the tool or over- use of the tool also. To achieve these Quality and Safety features within our Health Care System, a redesign is most likely needed and patient goals need to be at the forefront of every discussion and identifying the best possible way to meet these goals. All patients don’t all have the same goals, so guidelines, policies, procedures, and most of all, the patient individual Blueprint, are to be put in place, so that we can achieve patients best result of quality and safe care from best practices: evidence based.

Discussion 1: Quality and Safety in Healthcare and Nursing Practice Reference:

Institute of Medicine (U.S) Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new  health system for the 21st century. National Academies Press.

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

Quality and safety are the driving force behind delivering and promoting optimal care (Stalter & Mota, 2018). My primary role as a clinical nurse is to provide high-quality, patient-centered care using evidence-based practice. Before giving any care or medication dispensing, I include EBP into the routine. In my current role, I noticed that my colleagues rely on post-education, and I feel that approach is integrated at the wrong time, which is usually after an incident or error has occurred. I strongly believe in pre-education and promoting evidence-based practice in nursing.

I work on a 23-bed Med-Surg unit, and Friday mornings are the busiest surgical days. On this morning, a nurse administered a patient scheduled for Coronary Artery Bypass Graft (CABG) 20 units of Aspart and 15 units of Regular for a blood sugar of 206. Unfortunately, the patient had been NPO after midnight before the day of surgery. In the meantime, as we continued to make rounds and administer morning medications on the unit, the nurse received a call from the telemetry unit that the patient heart rhythm converted from normal sinus rhythm to ventricular tachycardia. The staff quickly went to the bedside and noted the patient to be diaphoretic, lethargic with a heart rate sustaining in the 130-150’s.

Immediately we had to call the rapid response team for further assistance. After the team arrived and was given a full report on the patient, the team administered IV antiarrhythmic medication to aid with the heart rate and a bolus of IV fluids for the blood pressure. Then, of course, the surgery was postponed, and the patient was transported to the ICU for closer observation. At shift change, the nurses had to report on what happened and how the patient received such a high insulin dose. Any high-alert medications must have two verifiers; only one nurse verified and administered the drug, which led to the error above. After further investigation, it was a computer error because it did not prompt the alert box for an additional signer. In addition, the nurse who administered the medication was new to the unit. I’m not making any excuses; however, the nurse should have verified the insulin order with the charge nurse or the ordering provider. Also, the ordering provider should have discontinued the order before surgery, which could have prevented the error. Therefore, thorough education and the implementation of evidence-based practice are imperative in nursing.

 

Role as a DNP-Prepared Nurse

As a DNP-Prepared nurse, I intend to integrate evidence-based practice by developing our organizational culture that supports best practice and promotes opportunities for staff to enhance their clinical skills and knowledge. With the healthcare system being so complex, as a DNP-prepared nurse, promoting a healthy work environment is an effective solution to promoting quality improvement and being proactive in preventing errors or glitches before they occur (Abdul, Jarrar & Don, 2015). In addition, I would advocate for the implementation of evidence-based practice throughout the nursing unit and organization by educating nurses on skills, such as critical appraisal and translation of research findings into practice (Tu & Wang, 2011). Furthermore, in my role as a DNP-prepared nurse, I can use error prevention strategies by continuously monitoring outcomes and completing root cause analysis when errors occur, including the input from clinical staff and the leadership team.

 

Discussion 1: Quality and Safety in Healthcare and Nursing Practice References:

Abdul, R.H., Jarrar, M., & Don, M.S. (2015).  Nurse level of education, quality of care and

patient safety in the medical and surgical wards in Malaysian private hospitals: A cross-

sectional study. Global Journal of Health Sciences.7(6):331-337. doi: 10.5539/gjhs.v7n6p33.

Stalter, A., & Mota, A. (2018). Using systems thinking to envision quality and safety

in healthcare, Nursing Management. Volume 49(2): doi:

10.1097/01.NUMA.0000529925.66375.d0.

Tu, Y.C., & Wang, R.H. (2011). High-quality nursing health care environment: The patient

safety perspective. Hu Li Za Zhi 58(3): 93-8. https://pubmed.ncbi.nlm.nih.gov/21678259.

The promotion of safety and quality is important in the provision of nursing care. Safety and quality in healthcare enhances the realization of optimum health outcomes in patient care. Nurses and other healthcare providers utilize sources of evidence-based data and practice guidelines to ensure safety and quality in their care. They also adopt best leadership models that will drive consistency in the provision of excellent care to patients. Therefore, this paper explores the issue of surgical site infections, best practices for its prevention, proposed project to address it and its evaluation. It also explores an effective leadership model that can be adopted to address the problem.

Best Practices or Recommended Guidelines

The selected issue from the Institute for Healthcare Improvement (IHI) that is relevant to my organization is surgical site infections. Surgical site infections comprise a critical public health concern that causes significant mortality, morbidity and increased cost of care. Surgical site infections are preventable, with the adoption of evidence-based interventions. A number best practices and recommended guidelines have been developed for prevention of surgical site infections. One of them is the World Health Organization (WHO) Surgical Safety Checklist and Getting Started Kit. The kit was developed to improve the quality and safety of patients undergoing surgeries globally. The tool reinforces the accepted safety principles and enhances the quality of teamwork and communication between clinical teams involved in surgical procedures and care of patients requiring and after surgeries. The other guideline that can be adopted to prevent surgical site infections is the How-to-Guide by IHI. The tool provides guidelines for use in the prevention of surgical site infections, implementation of recommended strategies and measures for assessing improvements (IHI, n.d.). Sources of evidence-based data show that best practices exist for use in prevention of surgical site infections. They include the use of aseptic techniques, negative pressure wound therapy, surgical bundles of safety and quality improvement, perioperative antibiotic prophylaxis, and reducing the duration of surgical procedure reduces and minimizes the rate of surgical site infections in a hospital setting (Allegranzi et al., 2018; Balch et al., 2017; Cheng et al., 2017; Javed et al., 2019).

Financial Impact

Surgical site infections have adverse financial implications. The existing evidence shows that surgical site infections cost the US about $3.5 to $10 billion on an annual basis. Additional statistics shows that surgical site infections increase the costs of care for commercial payers to a range of $36249 to $144809 and $17551 to $102280 for Medicare users in the US. The increase in the cost of care is attributable to factors such as prolonged hospitalization; intensive care unit stays, increased rates of hospital readmission, lost productive days, and need for additional care in the community (Leaper et al., 2020). Surgical site infections also increase the need for re-operations, reduced quality of life for patients and increased risk of mortality. The intangible costs that patients incur due to the infections such as anxiety, pain, and delayed wound healing that can cause complications including bacteremia (Badia et al., 2017). Healthcare institutions also suffer from the problem due to increased costs of patient care and resource utilization in the promotion of the optimum health and wellbeing of the patients.

Implementing the Project

The Plan-Do-Study-Act model can be applied in implementing my project. The model can be used to facilitate accelerated improvement in project processes. The PDSA model informs the strategies utilized in the change initiative. It also guides the development of a team that would lead the implementation process. The components of the model such as planning enable the project managers to understand the needs of the organization and the implementers of the project and ways of addressing them. The effective use of the model enables the systematic implementation of change initiatives in a project. Through it, organizations benefit from the gradual and organization wide successful implementation of a project (Newcombe & Fry-Bowers, 2018). Therefore, the PDSA model is applicable to my project, as it will minimize the risk of resistance from the adopters and failure due to ineffective processes.

Project to Address the Problem

A project that I could implement to address the issue of surgical sites infection in the institution is antibiotic prophylaxis. The administration of antibiotic prior to surgery has been shown to reduce the risk and rate of surgical site infections. The type of surgery determines largely the prophylactic antibiotics that patients should receive (Balch et al., 2017). The development and implementation of an antibiotic prophylactic protocol for use in the organization may therefore reduce the vulnerability of post-surgical patients to surgical site infections.

The PDSA model can be applied in the implementation of the prophylactic antibiotic protocol to be used in the organization. Activities such as recruiting a team to implement the project will be undertaken in the planning stage. The team will develop the mission and vision of the project in facilitating the realization of the desired safety and quality goals in the organization. The team will also develop an aim statement that would guide the development of the strategies. They will determine the causes of the problem and alternative interventions that can be used to address the problem. The team will lead the implementation of the selected alternatives in the do phase. They will embrace interventions such as training the healthcare providers about the implementation of the protocol and guiding its use in practice. The team will also collect data related to the effectiveness of the adopted strategies and consistency of protocol use by the staffs in this phase (Newcombe & Fry-Bowers, 2018). The assessment data informs the improvement strategies utilized to ensure the successful and organization wide implementation of the project.

The team evaluates whether the data answers the aim statement in the study phase. They utilize the results obtained in the do phase to evaluate the effectiveness of the project in reducing surgical site infections and improvement strategies that are needed in the organization. The implementation of organization wide use of the protocol occurs in the act phase. The phase occurs if the team determines the protocol to be effective in addressing the critical safety and quality needs in the organization (Katowa-Mukwato et al., 2021). They also communicate the success of the project to the organizational stakeholders, including the nurses and physicians.

Quality Improvement Measures

Quality improvement measures provide insights into the effectiveness of a project in delivering its expected outcomes. Outcome and process measures will be used to track improvement in the project. Outcome measures will focus on the evaluation of whether the desired results of the project were achieved or not. Outcome measures reflect the effectiveness of the adopted strategies in project implementation. Some of the outcome measures that will be used to track improvement will include the rate of surgical site infections, average hospital stay an costs incurred by patients in the organization. Process measures will facilitate the tracking of the effectiveness of the strategies used to achieve the project outcomes. It will focus on the effectiveness of strategies such as training, coaching, mentoring, and institutional support in ensuring the success of the project. Tools such as interviews and surveys will be used to obtain provider insights into the effectiveness of the strategies that were used in the implementation of the project (Zywot et al., 2017). The consistency of use of the protocol by the healthcare providers will also be used as a way of tracking the effectiveness of the project.

Quality Improvement Tools

A flow chart will be used for analyzing and monitoring the effectiveness of the project in addressing the issue of surgical site infections in the organization. A flow chart will be desirable, as it will provide efficient tracking of the project activities. It will also facilitate the determination of effective and ineffective strategies in the implementation of the project. Through it, redundancies and duplication of processes and roles will be eliminated. A flow chart is also desirable, as it will facilitate effective ordering and organizing of the activities needed to achieve the desired project objectives.

Leadership Theory

The leadership theory that would be applied in the implementation of the project is servant leadership theory. Servant leadership theory is a model where leaders aim at serving and meeting the needs of those they lead. Leaders focus on creating a synergistic relationship with those they lead that than controlling relationship. The leaders recognize the need for the prioritization of the needs of those they lead in project implementation. As a result, they motivate them to play a proactive role in the different phases of project implementation such as assessment, planning, monitoring, and evaluation. Servant leaders also aim at promoting innovation. They encourage their followers to explore effective ways in which optimum outcomes in strategy implementation can be achieved (Best, 2020). They also empower their followers by encouraging their active participation in the project initiatives. Servant leaders also promote open communication between and among the followers. They recognize the importance of openness in communication in fostering trust and honesty among the project members (Neville et al., 2021). Therefore, I  believe that servant leadership will facilitate the realization of optimum outcomes in the implementation of the protocol to reduce surgical site infections in the organization.

Discussion 1: Quality and Safety in Healthcare and Nursing Practice Conclusion

Overall, surgical site infections comprise a critical issue in healthcare organizations. Surgical site infections are attributable to organizational factors that can be controlled. The financial impacts of surgical site infections to patients and healthcare institutions are enormous. Protocols such as prophylactic administration of antibiotics are effective in preventing and minimizing surgical site infections. The PDSA model can be used in the implementation of a project aiming at the use of the protocol in the institution. The model guides systematic implementation of the project with a focus on minimizing resistance from the staffs. Servant leadership should therefore be applied to ensure the realization of the desired institutional outcomes in the prevention and minimizing of surgical site infections using the protocol.

 

 

Discussion 1: Quality and Safety in Healthcare and Nursing Practice References

Allegranzi, B., Aiken, A. M., Zeynep Kubilay, N., Nthumba, P., Barasa, J., Okumu, G., Mugarura, R., Elobu, A., Jombwe, J., Maimbo, M., Musowoya, J., Gayet-Ageron, A., & Berenholtz, S. M. (2018). A multimodal infection control and patient safety intervention to reduce surgical site infections in Africa: A multicentre, before–after, cohort study. The Lancet Infectious Diseases, 18(5), 507–515. https://doi.org/10.1016/S1473-3099(18)30107-5

Badia, J. M., Casey, A. L., Petrosillo, N., Hudson, P. M., Mitchell, S. A., & Crosby, C. (2017). Impact of surgical site infection on healthcare costs and patient outcomes: A systematic review in six European countries. Journal of Hospital Infection, 96(1), 1–15. https://doi.org/10.1016/j.jhin.2017.03.004

Balch, A., Wendelboe, A. M., Vesely, S. K., & Bratzler, D. W. (2017). Antibiotic prophylaxis for surgical site infections as a risk factor for infection with Clostridium difficile. PLOS ONE, 12(6), e0179117. https://doi.org/10.1371/journal.pone.0179117

Best, C. (2020). Is there a place for servant leadership in nursing? Practice Nursing, 31(3), 128–132. https://doi.org/10.12968/pnur.2020.31.3.128

Cheng, H., Chen, B. P.-H., Soleas, I. M., Ferko, N. C., Cameron, C. G., & Hinoul, P. (2017). Prolonged Operative Duration Increases Risk of Surgical Site Infections: A Systematic Review. Surgical Infections, 18(6), 722–735. https://doi.org/10.1089/sur.2017.089

IHI. (n.d.). Surgical Site Infection | IHI – Institute for Healthcare Improvement. Retrieved October 23, 2021, from http://www.ihi.org:80/Topics/SSI/Pages/default.aspx

Javed, A. A., Teinor, J., Wright, M., Ding, D., Burkhart, R. A., Hundt, J., Cameron, J. L., Makary, M. A., He, J., Eckhauser, F. E., Wolfgang, C. L., & Weiss, M. J. (2019). Negative Pressure Wound Therapy for Surgical-site Infections: A Randomized Trial. Annals of Surgery, 269(6), 1034–1040. https://doi.org/10.1097/SLA.0000000000003056

Katowa-Mukwato, P., Mwiinga-Kalusopa, V., Chitundu, K., Kanyanta, M., Chanda, D., Mbewe Mwelwa, M., Ruth, W., Mundia, P., & Carrier, J. (2021). Implementing Evidence Based Practice nursing using the PDSA model: Process, lessons and implications. International Journal of Africa Nursing Sciences, 14, 100261. https://doi.org/10.1016/j.ijans.2020.100261

Leaper, D. J., Holy, C. E., Spencer, M., Chitnis, A., Hogan, A., Wright, G. W. J., Po-Han Chen, B., & Edmiston, C. E. J. (2020). Assessment of the Risk and Economic Burden of Surgical Site Infection Following Colorectal Surgery Using a US Longitudinal Database: Is There a Role for Innovative Antimicrobial Wound Closure Technology to Reduce the Risk of Infection? Diseases of the Colon & Rectum, 63(12), 1628–1638. https://doi.org/10.1097/DCR.0000000000001799

Neville, K., Conway, K., Maglione, J., Connolly, K. A., Foley, M., & Re, S. (2021). Understanding Servant Leadership in Nursing: A Concept Analysis. International Journal for Human Caring. https://doi.org/10.20467/HumanCaring-D-20-00022

Newcombe, J., & Fry-Bowers, E. (2018). Improving Postoperative Neonatal Nutritional Practices in an Intensive Care Unit Using the PDSA Cycle. Journal of Pediatric Health Care, 32(5), 426–434. https://doi.org/10.1016/j.pedhc.2018.03.004

Zywot, A., Lau, C. S. M., Stephen Fletcher, H., & Paul, S. (2017). Bundles Prevent Surgical Site Infections After Colorectal Surgery: Meta-analysis and Systematic Review. Journal of Gastrointestinal Surgery, 21(11), 1915–1930. https://doi.org/10.1007/s11605-017-3465-3