XQ4005 Assignment Quality Improvement Plan

Speaker Notes

Slide 1

Welcome. The focus of this presentation is to identify three quality care issues that would be applicable on a medical-surgical nursing unit, give evidence for these, and suggest a solution for a nurse-initiated change using Lewin’s Change Theory.

Slide 2

Patient falls are among the most common preventable ancillary events that occur in hospitals. Med-surg units also pose risks like polypharmacy and post-op weakness that can be directly addressed by nurses daily by screening and rounding. HAPs are just as preventable and have a patient safety and monetary impact on the organization because they are no longer reimbursable by CMS. Both problems are nurse-intervention, low-cost staffing changes.

Slide 3

The third identified problem: Medication administration errors. Nurses dispense the bulk of drugs and are the first line of defense between a drug and the patient. At a unit level, strategies like BCMA and interruption-free zones are all in the nurses’ hands. All three of the problems were specifically selected because they are measurable and can be impacted by nurses, and not dependent on staffing ratios or system-wide restructuring.

Slide 4

The AHRQ is a federal patient safety agency, and the fall prevention toolkit is the national standard being used by hospitals all over the U.S. These statistics, a million falls annually, $30,000 for every fall, set the size and seriousness of the problem. The NPIAP is the authority to which The Joint Commission refers for HAPIs. Their clinical practice guidelines state that most pressure injuries can be prevented, thus highlighting this as a potential quality problem that nurses can affect.

Slide 5

ISMP is a non-profit organisation entirely focused on the issue of medication safety, and is recognised internationally. They use their acute care alerts throughout the country in policy formation. Nurse-administered errors and suggestions for nurse-controlled safeguards, double-checks, and interruption-free zones are specifically identified and give this source direct relevance and credibility to substantiate MAEs as a problem at the quality unit level.

Slide 6

The choice of patient falls for the use of Lewin’s is because there is strong evidence and clear interventions. Stage 1 is when staff’s efforts are directed towards disrupting the status quo; they won’t change unless there is an understanding of why the status quo is a problem. That urgency comes from providing real data at the national benchmark level and conducting a root cause analysis. The Fall Prevention Bundle is the change in Stage 2, as it is a multi-component intervention because the AHRQ findings indicate that single interventions have not yielded sustained results.

Slide 7

Changes don’t stick because the most often missed step is refreezing. This is achieved by embedding the bundle within the policy, the EHR, and the unit culture (with the help of a quality champion); this results in three layers of accountability. The expected results are the measurable outcomes: Reduce fall rates (using EHR data), Rounding compliance (using audit reports), and Injury reduction (using incident reports). This gives the organisation a clear indication of the success or failure of the change.