MSN Writing Services

NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal

New Samples

Struggling With Your Assessments? Get Help From Our Tutors

    NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal

    Student Name

    Capella University

    NURS-FPX 6016 Quality Improvement of Inter-professional Care

    Prof. Name

    Date

    Data Analysis and Quality Improvement Initative Proposal

    Good morning everyone. The topic for today’s presentation is data analysis and quality improvement initiative proposal on a health care issue that will be discussed throughout the presentation. It is the primary responsibility of healthcare professionals to provide quality care to their patients and work together to improve patient safety. To fulfill this essential duty it is significant for a healthcare organization to promote interprofessional collaboration among the employees, ensure effective leadership styles are utilized and healthcare workers are encouraged to incorporate evidence-based strategies in their practices.

    For this purpose and improvement of quality, leaders, and management of any healthcare organization plays an important role in successfully implementing the QI initiatives and achieving desirable outcomes. This presentation is based on a similar QI initiative that is proposed for the Vila Health facility where an incidence of adverse drug events provoked the management and other stakeholders to take effective interventions to preserve patients’ safety in terms of medication. 

    Health Care Problem –Adverse Drug Events (ADEs)

    Adverse drug events are defined as those incidences where a patient is harmed due to exposure to a medication or because of a medication error that occurred due to poor quality of care. To understand it better, medication errors that occur at any stage of the medication process from prescription to administration, can lead to undesirable harm to the patients (Patient Safety Network AHRQ, 2019). Research states that the high-risk population encounters adverse drug events in elderly patients as they have multiple comorbidities for which several medication regimens are followed which can lead to adverse drug reactions or medication errors (Choi et al., 2022). Further study concluded that about 16-18 patients from 100 patients face various ADEs, which increase the mortality rate between 8.8-9.5% (Sahilu et al., 2020) and approximately 50% of these events are avoidable (Ersulo et al., 2022). 

    Adverse drug events are not only harmful to the physical health of the patients but they also impact the finances of the hospitals. Research indicates that around $5.6 million is spent annually on ADEs by various hospitals in the US (Choi et al., 2022). Hence this is also an eye-opening challenge of adverse drug events and requires extensive efforts from the hospital management to initiate a quality improvement plan for safe practices and reduction in the costs associated with ADEs. A report from the patient safety and quality department of the Vila Health facility that recorded adverse drug events in the year 2021 to 2022 is presented in this presentation. 

    Analysis of Dashboard Metrics Related to ADEs

    The statistical dashboard of Vila Health facility considered five major metrics to prepare this safety and quality report. The metrics are

    • Number of adverse drug events
    • Common risk factors leading to these ADEs
    • Length of stay as compared to usual treatment days
    • The rate of readmissions that occurred due to ADEs
    • And the incidences of patient death related to adverse drug reactions (Patient Safety Network AHRQ, 2019; Stone et al., 2018). 

    The quality of the data available is helpful in that the number of patients encountering adverse drug events has minimally reduced between both years however, the risk factors associated remained the same. The concerning point concluded from this data is the increasing length of stay and a significant increase in the readmissions rate. Although death incidences have decreased, leadership is still required to take quality improvement initiatives to further improve the results and ensure patients’ safety. These outcomes are concerning for the stakeholders of Vila Health facility – the patients, nurses, doctors, leaders, and policymakers.

    NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal

    Increased rate of readmissions is one of the major concerns as it is harmful to patients’ health as well as puts a financial burden on the hospitals. According to research, the Hospital Readmissions Reduction Program (HRRP) which was established by Patient Protection and Affordable Care Act, puts a hefty penalty by reducing Medicare expenses on the hospitals which have greater readmission rates. The purpose of this program is to reduce readmissions, minimize hospital costs associated and improve patients’ safety (Gai & Pachamanova, 2019). Thus hospitals need to improve communication and coordination among healthcare professionals to perform practices that are in favor of patients’ safety (Centers for Medicare and Medicaid Services, 2023).

    Another concern is the increased length of stay. A study identifies that most of the ADEs which result in increased length of stay are preventable and targeting those patients with an extended hospital stay due to preventable adverse events is an important action for stakeholders (Ersulo et al., 2022). These pieces of evidence are advocating the need for solutions and a quality improvement initiative. 

    Outlining Quality Improvement Initiative 

    Leadership plays an important role in encouraging employees to work for better patient outcomes and improve the quality of care. The quality improvement initiative proposed against adverse drug events includes three major strategies a) initiation of technologies for the overall medication process, b) constant professional training is recommended for healthcare professionals, and c) appropriate use of hands-off methods. 

    Technology-Assisted Medication Process

    Adverse events related to medications can occur at any stage of the medication process (prescribing- administering), hence the introduction of technologies like computerized physician order entry (CPOE), electronic health information, and machine-readable coded systems are essential at every stage for correct prescription, right drug preparation and dispensing as well as right administration (Hajesmaeel Gohari et al., 2020; Schneider, 2018). The introduction of some of these technologies in Vila Health will reduce the discrepancies between the medications which are prescribed and administered. Moreover, this will act as a warning system for healthcare professionals before committing a malpractice action. 

    Continuous Professional Training 

    Research on the implementation of medication safety programs resulted that training related to medication safety improves the knowledge of healthcare professionals, increases their confidence, encourages positive behavior, and assists them in using the knowledge in their practices (Khalil & Lee, 2018). Continuous professional training also helps managers to assess the clinical competencies of healthcare professionals and take appropriate actions for improvement so that patient safety is ensured. 

    Proper Hands-off

    Handover/hands-off is a process where the exchange of information and responsibility takes place between healthcare professionals. Proper hands-off is important to maintain the continuity of care and ensure patients’ safety. It is estimated that around 40% of adverse events occur due to improper hands-off communication (Kim et al., 2021). It is recommended in this QI initiative to initiate a hands-off form and add a component of medications in that form so that no information is missed, and patients are provided quality care. 

    The areas of uncertainty and missing information are the availability of human and financial resources. If the organization doesn’t have excess human resources for the implementation of the plan, it will first require the hiring of personnel so that an interprofessional team is built. Moreover, financial resources are required to introduce new technologies for medication safety. Thus, this QI initiative has a knowledge gap about the availability of resources at the Vila Health facility which would have helped in further improving the proposal. 

    To achieve desirable outcomes, interprofessional collaboration is significant. This QI initiative will also highlight the perspectives and actions required by the interprofessional team to ensure patients’ safety, cost reduction, and maintenance of work and life quality for healthcare professionals. 

    Interprofessional Perspectives and Actions needed for QI initiative 

     To successfully implement a QI initiative and obtain desired outcomes, it is essential for an interdisciplinary team to collaboratively work together and the primary group of people responsible for this is nurses being the frontline staff (Brugman et al., 2022). Various interprofessional perspectives in healthcare act as guidelines for improving health quality and safety. Interprofessional perspectives that are suitable for Vila Health in terms of implementing a QI initiative are the use of a transformational leadership style and effective communication strategies. 

    Transformational leadership is defined as the behaviors of a leader which influence the employees so that they can perform better and find solutions to problems effectively. The research concludes that leaders who equip a transformational style are more likely to contribute positively to patients’ safety. Moreover, it is also connected with maintaining a good work environment which in turn helps the healthcare workers to improve their work-life balance, improving their healthcare practices for patients’ safety and eventually reducing the costs associated with poor quality of care (Khan et al., 2020; Seljemo et al., 2020). 

    Effective communication means timely communicating the correct information. Nurses play an important role in this matter to ensure quality care is provided and patients’ safety is maintained. Impaired communication is a lack of adequate information that can lead to patient harm thus the use of effective communication is encouraged in healthcare facilities (Fuchshuber & Greif, 2022; Jang et al., 2022). According to the AHRQ communication between healthcare providers is the most important in terms of creating a patient safety culture.

    NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal

    The strategies recommended are bedside team rounds, proper handover, simulation-based closed-loop communication, and appropriate verbal communication (Patient Safety Network AHRQ, 2021). In terms of cost reduction, a study mentions that overcoming communication barriers in healthcare can reduce approximately 671,440 preventable adverse events which save around $6.8 billion yearly. These communication barriers consist of both patient-provider and provider-provider relationships (Hurtig et al., 2018). 

    The actions that interprofessional teams need to take to improve the quality of care are role specific. Nurses, doctors, and pharmacists are the pivotal group of people in this matter because every intervention that is planned at the administrative level will be undertaken in clinical areas by them hence they must ensure to be vigilant and perform their practices keeping in mind patient-centeredness to ensure patients’ safety. Educators are responsible to prepare curriculum, plan training sessions (weekly, monthly, quarterly, and yearly) for healthcare workers and establish evaluations for checking their knowledge related to safe practices.Leaders must analyze the data related to adverse drug events and collaborate with the administration of the hospital to introduce new policies and technologies for improved outcomes.

    Similarly, the administration/board of directors is responsible for bringing organizational changes in policies, procedures, and standards and should take part in the introduction of interventions that require human and financial resources. The assumptions on which the suggestions are based is the importance of interprofessional collaboration and teamwork in healthcare systems to overcome and reduce adverse events (Laird et al., 2020). Moreover, with the advancing world, there is a constant need for organizational change in healthcare for improving the quality of care with time and ensuring patients’ safety hence it is essential to develop QI initiatives and follow the suggestions recommended. 

    Collaboration Strategies for Improving Quality Care 

    As discussed, interprofessional collaboration is essential for the implementation of the QI initiative as well as for achieving desired outcomes. The strategies to ensure interprofessional collaboration and improve quality care are a) interprofessional education (IPE), b) interprofessional leadership, c) teamwork in practice and care, and d) interprofessional research and QI. It is important to consider the factors of communication, role clarification (where every individual is aware of their roles and limitations), interprofessional ethical values are considered, reflection on the practices and care, and shared decisions are made to ensure that the care provided is for patients’ safety (McLaney et al., 2022; Shakhman et al., 2020). 

    Conclusion

    To conclude the presentation, I would like to summarize that Adverse drug events are a significant health problem in healthcare which most commonly occurs in the elderly population. Every healthcare professional must address this issue to ensure patients’ safety. Moreover, nurses, doctors, and pharmacists are a primarily responsible group of people hence they must ensure their practices are with the code of conduct and result in positive outcomes for the patients.

    Nurse educators play a crucial role in encouraging a safety culture in hospitals. This presentation analyzed data presented by Vila Health and three evidence-based solutions are proposed (continuous training, initiation of technologies, and introduction of hands-off forms with medication component). To improve quality care interprofessional collaboration, effective leadership, and appropriate communication techniques are beneficial to address the problem and initiate a quality improvement plan for successful results. 

    References

    Brugman, I. M., Visser, A., Maaskant, J. M., Geerlings, S. E., & Eskes, A. M. (2022). The evaluation of an interprofessional qi program: A qualitative study. International Journal of Environmental Research and Public Health19(16), 10087. https://doi.org/10.3390/ijerph191610087  

    Centers for Medicare and Medicaid Services. (2023). Hospital readmissions reduction program (HRRP). https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program  

    Choi, E., Kim, S., & Suh, H. S. (2022). Exploring the prevalence and characteristics of adverse drug events among older adults in South Korea using a national health insurance database. Frontiers in Pharmacology13. https://doi.org/10.3389/fphar.2022.1047387

    Ersulo, T. A., Yizengaw, M. A., & Tesfaye, B. T. (2022). Incidence of adverse drug events in patients hospitalized in the medical wards of a teaching referral hospital in Ethiopia: A prospective observational study. BMC Pharmacology and Toxicology23(1). https://doi.org/10.1186/s40360-022-00570-w  

    Fuchshuber, P., & Greif, W. (2022). Creating effective communication and teamwork for patient safety. The SAGES Manual of Quality, Outcomes and Patient Safety, 443–460. https://doi.org/10.1007/978-3-030-94610-4_23 

    Gai, Y., & Pachamanova, D. (2019). Impact of the medicare hospital readmissions reduction program on vulnerable populations. BMC Health Services Research19(1). https://doi.org/10.1186/s12913-019-4645-5  

    Hajesmaeel Gohari, S., Bahaadinbeigy, K., Tajoddini, S., & R. Niakan Kalhori, S. (2020). Effect of computerized physician order entry and clinical decision support system on adverse drug events prevention in the emergency department: A systematic review. Journal of Pharmacy Technology37(1), 53–61. https://doi.org/10.1177/8755122520958160 

    NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal

    Hurtig, R. R., Alper, R. M., & Berkowitz, B. (2018). The cost of not addressing the communication barriers faced by hospitalized patients. Perspectives of the ASHA Special Interest Groups3(12), 99–112. https://doi.org/10.1044/persp3.sig12.99  

    Jang, H., Lee, M., & Lee, N.-J. (2022). Communication education regarding patient safety for registered nurses in Acute Hospital Settings: A scoping review protocol. BMJ Open12(2). https://doi.org/10.1136/bmjopen-2021-053217  

    Khalil, H., & Lee, S. (2018). The implementation of a successful medication safety program in a primary care. Journal of Evaluation in Clinical Practice24(2), 403–407. https://doi.org/10.1111/jep.12870  

    Khan, H., Rehmat, M., Butt, T. H., Farooqi, S., & Asim, J. (2020). Impact of transformational leadership on work performance, burnout and social loafing: A mediation model. Future Business Journal6(1). https://doi.org/10.1186/s43093-020-00043-8  

    Kim, J. H., Lee, J. L., & Kim, E. M. (2021). Patient safety culture and handoff evaluation of nurses in small and medium-sized hospitals. International Journal of Nursing Sciences8(1), 58–64. https://doi.org/10.1016/j.ijnss.2020.12.007 

    Laird, Y., Manner, J., Baldwin, L., Hunter, R., McAteer, J., Rodgers, S., Williamson, C., & Jepson, R. (2020). Stakeholders’ experiences of the Public Health Research Process: Time to change the system? Health Research Policy and Systems18(1). https://doi.org/10.1186/s12961-020-00599-5 

    McLaney, E., Morassaei, S., Hughes, L., Davies, R., Campbell, M., & Di Prospero, L. (2022). A framework for interprofessional team collaboration in a hospital setting: Advancing team competencies and behaviours. Healthcare Management Forum35(2), 112–117. https://doi.org/10.1177/08404704211063584  

    Patient Safety Network. (2021). Approach to improving patient safety: Communication. https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication

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

    NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal

    Patient Safety Network AHRQ. (2019). Measurement of Patient Safety. https://psnet.ahrq.gov/primer/measurement-patient-safety 

    Sahilu, T., Getachew, M., Melaku, T., & Sheleme, T. (2020). Adverse drug events and contributing factors among hospitalized adult patients at Jimma Medical Center, southwest Ethiopia: A prospective observational study. Current Therapeutic Research93, 100611. https://doi.org/10.1016/j.curtheres.2020.100611  

    Schneider, P. J. (2018). The impact of technology on safe medicines use and pharmacy practice in the US. Frontiers in Pharmacology9. https://doi.org/10.3389/fphar.2018.01361 

    Seljemo, C., Viksveen, P., & Ree, E. (2020). The role of transformational leadership, job demands and job resources for patient safety culture in Norwegian nursing homes: A cross-sectional study. BMC Health Services Research20(1). https://doi.org/10.1186/s12913-020-05671-y  

    Shakhman, L. M., Al Omari, O., Arulappan, J., & Wynaden, D. (2020). Interprofessional education and collaboration: Strategies for implementation. Oman Medical Journal35(4). https://doi.org/10.5001/omj.2020.83 

    Stone, A. B., Jones, M. R., Rao, N., & Urman, R. D. (2018). A dashboard for monitoring opioid-related adverse drug events following surgery using a national administrative database. American Journal of Medical Quality34(1), 45–52. https://doi.org/10.1177/1062860618782646