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NURS 8302 Discussion Identifying Practice Gaps for Quality Improvement

NURS 8302 Discussion Identifying Practice Gaps for Quality Improvement

NURS 8302 Discussion Identifying Practice Gaps for Quality Improvement

Identifying practice gap for quality improvement

Diabetes has become a national epidemic affecting about 29.1% of Americans, approximately 9.3% of the population (Shirivastav et al., 2018).  Yet, an estimated 20 % remain undiagnosed, while the annual new case estimate is about 1.4 million (Shirivastav et al., 2018). In 2013, among patients seeking medical primary care visits, diabetes was the fifth-ranked primary diagnosis according to the centers for disease control and prevention center (2021). Hence, one can argue how essential primary care is to effectively screen, diagnose, and manage patients with type Two diabetes, realizing the implications of poor control, leading to disease progression to chronic complications such as microvascular and macrovascular diseases or possible life-threatening hypoglycemia.

According to the standards of diabetes care, controlling glucose improves Glyco hemoglobin (HbA1c) levels over time. Other factors associated with delaying complications are maintaining target blood pressure and lowering low-density cholesterol levels, which prevents chronic complications of diabetes. Therefore, primary care centers must make a concerted effort to adopt the national standards of care by developing a quality improvement program by identifying gaps to prevent poor patient outcomes leading to poor compliance.  Examples of such gaps include poor glucose control goals in patients with type 2 diabetes as evidence by HbA1c not at goal rate, patients with diabetes not achieving target blood pressure goal of 130/80 and low-density lipoprotein cholesterol levels above the target rate (Kitson, & Straus, 2010).

The quality improvement gap I would like to address at my current clinic is improving HbA1c to goal range among patients above the target range. This facility has a quality improvement team comprising a nurse manager, behavioral health, nurses, Nurse practitioners, and medical assistants. Evidence-based standards of practice emphasize patients with HBA1c greater than 7% repeat testing within six weeks. Using the PDSA method by predicting a clear outcome of HbA1c of <7% (Taylor & Bircher, 2016).

Plan: Decide on one team member to send out appointment reminders to patients with HbA1c above target, would measure the time between the out-of-target HbA1c received, review appointment, and when they would introduce the change (Taylor & Bircher, 2016).

Next is the Do section here, when the team monitors if there is an increased workload for the nursing because of increased appointments and patient compliance. The study phase is after three to six months, data is collected and analyzed, and finally, the Act phase is where the team acts on the positive change determines (IHI. 2021). Additionally, in this action phase, the team can publish the PDSA findings for implementation in the clinic or adjust for further improvement. The second tool applicable to improving glycemic control is the lean six sigma which focuses on defects. I will use this method to develop a nursing workflow in facilitating intervention to improve glycemic control (Kollipara et al., 2021). Finally, utilizing these two quality measures will improve the identified gaps and enhance euglycemia among patients with type 2 diabetes at the community-based clinic.

References:

Centers for Disease Control and Prevention. (2021). Ambulatory care use and physician office visits. https://www.cdc.gov/nchs/fastats/physician-visits.htm.

Institute for Healthcare Improvement (IHI), (2021).  http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx

Kollipara, U, Rivera-Bernuy, M., Putra, J., Burks, J., Meyer, A., Ferguson, S., Nelson, C., Mutz, J., Mirfakhraee, S., Bajaj, P., Kermani, A, Fish, J. S., and Ali, S. (2021). Improving diabetes control using lean six sigma quality improvement in an endocrine clinic in a large accountable care organization. Clinical Diabetes. 39(1): 57-63.

Shrivastav, M., Gibson, W Jr., Shrivastav, R., Elzea, K., Khambatta, C., Sierra, J. A., and Vigersky, R. (2018). Type 2 diabetes management in primary care: The role of retrospective professional continuous glucose monitoring. Diabetes Spectrum 31(3): 279-287.

Kitson, A. and Straus, S. E. (2010). The knowledge-to-action cycle: identifying the gaps. Canadian Medical Association Journal. 182(2): E73–E77.

Taylor, B and Bircher, J. (2016). The quality improvement tool kit for diabetes. Diabetes and Primary Care. 18(6):254-266

What should be happening in practice? What is happening or observed in practice?

These two questions aid in identifying potential quality improvement practice gaps in nursing practice. If we know what should be happening does not match what is happening, we know we have a problem, or more accurately, a practice gap.

The difference between a desirable or achievable state of practice and current reality is referred to as a practice gap. Healthcare associated infections (HAIs), such as central line associated blood stream infections (CLABSIs) or catheter associated urinary tract infections (CAUTIs), are a common practice gap in today’s healthcare organizations (CAUTIs).

The ongoing identification of practice gaps is critical to quality improvement, and it entails identifying the current state, comparing it to the desired state, identifying the causes of the gaps in practice, and validating those gaps to develop an improvement process.

Consider any quality improvement practice gaps in your practice or organization for this Discussion. Consider what methods and/or tools for quality improvement might be useful in closing this practice gap. Consider how you might approach these challenges and what strategies you might employ as a future DNP-prepared nurse.

To Prepare:

  • Review the Learning Resources on tools and methods for quality improvement.
  • Reflect on a potential quality improvement practice gap, you have seen in your practice or organization, which you might consider using for your DNP project.
  • Consider the tools and methods you might use to address this quality improvement practice gap.

By Day 3 of Week 3

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.

By Day 6 of Week 3

Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days by expanding upon your colleague’s post and suggesting alternative tools and/or methods your colleague might consider using to address the quality improvement practice gap they selected.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

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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 (4th 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

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Response

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

 

Content

Name: NURS_8302_Week3_Discussion_Rubric

  Excellent

90–100

 Good

80–89

 Fair

70–79

 Poor

: 0–69
Main Posting:

Response to the Discussion question is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.

 Points Range: 40 (40%) – 44 (44%)

Thoroughly responds to the Discussion question(s).

Is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.

No less than 75% of post has exceptional depth and breadth.

Supported by at least three current credible sources.

 Points Range: 35 (35%) – 39 (39%)

Responds to most of the Discussion question(s).

Is somewhat reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module.

50% of the post has exceptional depth and breadth.

Supported by at least three credible references.

 Points Range: 31 (31%) – 34 (34%)

Responds to some of the Discussion question(s).

One to two criteria are not addressed or are superficially addressed.

Is somewhat lacking reflection and critical analysis and synthesis.

Somewhat represents knowledge gained from the course readings for the module.

Cited with fewer than two credible references.

 Points Range: 0 (0%) – 30 (30%)

Does not respond to the Discussion question(s).

Lacks depth or superficially addresses criteria.

Lacks reflection and critical analysis and synthesis.

Does not represent knowledge gained from the course readings for the module.

Contains only one or no credible references.
Main Posting:

Writing

 Points Range: 6 (6%) – 6 (6%)

Written clearly and concisely.

Contains no grammatical or spelling errors.

Adheres to current APA manual writing rules and style.

 Points Range: 5 (5%) – 5 (5%)

Written concisely.

May contain one to two grammatical or spelling errors.

Adheres to current APA manual writing rules and style.

 Points Range: 4 (4%) – 4 (4%)

Written somewhat concisely.

May contain more than two spelling or grammatical errors.

Contains some APA formatting errors.

 Points Range: 0 (0%) – 3 (3%)

Not written clearly or concisely.

Contains more than two spelling or grammatical errors.

Does not adhere to current APA manual writing rules and style.
Main Posting:

Timely and full participation

 Points Range: 9 (9%) – 10 (10%)

Meets requirements for timely, full, and active participation.

Posts main Discussion by due date.

 Points Range: 8 (8%) – 8 (8%)

Meets requirements for full participation.

Posts main Discussion by due date.

 Points Range: 7 (7%) – 7 (7%)

Posts main Discussion by due date.

 Points Range: 0 (0%) – 6 (6%)

Does not meet requirements for full participation.

Does not post main Discussion by due date.
First Response:

Post to colleague’s main post that is reflective and justified with credible sources.

 Points Range: 9 (9%) – 9 (9%)

Response exhibits critical thinking and application to practice settings.

Responds to questions posed by faculty.

The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.

 Points Range: 8 (8%) – 8 (8%)

Response has some depth and may exhibit critical thinking or application to practice setting.

 Points Range: 7 (7%) – 7 (7%)

Response is on topic and may have some depth.

 Points Range: 0 (0%) – 6 (6%)

Response may not be on topic and lacks depth.
First Response:
Writing 		Points Range: 6 (6%) – 6 (6%)

Communication is professional and respectful to colleagues.

Response to faculty questions are fully answered, if posed.

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

Response is effectively written in standard, edited English.

 Points Range: 5 (5%) – 5 (5%)

Communication is mostly professional and respectful to colleagues.

Response to faculty questions are mostly answered, if posed.

Provides opinions and ideas that are supported by few credible sources.

Response is written in standard, edited English.

 Points Range: 4 (4%) – 4 (4%)

Response posed in the Discussion may lack effective professional communication. Response to faculty questions are somewhat answered, if posed.

Few or no credible sources are cited.

 Points Range: 0 (0%) – 3 (3%)

Responses posted in the Discussion lack effective communication.

Response to faculty questions are missing.

No credible sources are cited.
First Response:
Timely and full participation 		Points Range: 5 (5%) – 5 (5%)

Meets requirements for timely, full, and active participation.

Posts by due date.

 Points Range: 4 (4%) – 4 (4%)

Meets requirements for full participation.

Posts by due date.

 Points Range: 3 (3%) – 3 (3%)

Posts by due date.

 Points Range: 0 (0%) – 2 (2%)

Does not meet requirements for full participation.

Does not post by due date.
Second Response:
Post to colleague’s main post that is reflective and justified with credible sources. 		Points Range: 9 (9%) – 9 (9%)

Response exhibits critical thinking and application to practice settings.

Responds to questions posed by faculty.

The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.

 Points Range: 8 (8%) – 8 (8%)

Response has some depth and may exhibit critical thinking or application to practice setting.

 Points Range: 7 (7%) – 7 (7%)

Response is on topic and may have some depth.

 Points Range: 0 (0%) – 6 (6%)

Response may not be on topic and lacks depth.
Second Response:
Writing 		Points Range: 6 (6%) – 6 (6%)

Communication is professional and respectful to colleagues.

Response to faculty questions are fully answered, if posed.

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

Response is effectively written in standard, edited English.

 Points Range: 5 (5%) – 5 (5%)

Communication is mostly professional and respectful to colleagues.

Response to faculty questions are mostly answered, if posed.

Provides opinions and ideas that are supported by few credible sources.

Response is written in standard, edited English.

 Points Range: 4 (4%) – 4 (4%)

Response posed in the Discussion may lack effective professional communication.

Response to faculty questions are somewhat answered, if posed.

Few or no credible sources are cited.

 Points Range: 0 (0%) – 3 (3%)

Responses posted in the Discussion lack effective communication.

Response to faculty questions are missing.

No credible sources are cited.
Second Response:
Timely and full participation 		Points Range: 5 (5%) – 5 (5%)

Meets requirements for timely, full, and active participation.

Posts by due date.

 Points Range: 4 (4%) – 4 (4%)

Meets requirements for full participation.

Posts by due date.

 Points Range: 3 (3%) – 3 (3%)

Posts by due date.

 Points Range: 0 (0%) – 2 (2%)

Does not meet requirements for full participation.

Does not post by due date.
Total Points: 100