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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 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

NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation

Student Name Capella University NHS-FPX 6004 Health Care Law and Policy Prof. Name Date Dashboard Metrics Evaluation This report focuses on evaluating dashboard metrics based on national or state benchmarks. Various national, state, and local laws or policies provide healthcare systems with criteria to assess their healthcare performance by comparing the organization’s dashboard metrics and data. By assessing the dashboard metrics data with benchmark data, one can improve care treatment quality, enhance patient safety, and estimate the healthcare professionals’ performance in a particular clinical setup. For this purpose, this report compares the dashboard metrics data of Mercy Medical Center (MMC) with benchmarks set forth by the National Healthcare Quality and Disparities Report (NHQDR) to identify the shortcomings of MMC in providing care treatment to diabetics. Comparison and Contrast of Dashboard Metrics with NHQDR Benchmarks Mercy Medical Center is known for its high-quality care treatment in Shakopee City, as it has achieved various awards for providing the highest safe surgery and outstanding patient experience. The total population of Shakopee City comprises 36,192 individuals, out of which 18,235 are females and 17,957 include males. The age group primarily found in this population is 21-44, making up 14,732. In Public Health Dashboard on Diabetes provided by MMC, eye exams, foot exam, and HgbA1c test data is available, ranging from the first quartile of 2019 to the fourth quartile of 2020. Furthermore, the data measured also depicted the new patients admitted or visited MMC based on race, gender, and age. The total number of patients admitted to MMC in the last quarter of 2020 was 563. To evaluate the efficacy of care treatment for diabetics in MMC, comparing the dashboard metrics data with national benchmarks AHRQ sets is essential. The AHRQ has established a standard for eye exams to be 75.2 %, feet exams to be 84%, and HbA1C to be 79.5% (AHRQ, n.d.). Considering the last quarter of 2020, the patient admissions in MMC and the tests conducted in the last quarter are compared accordingly to examine underperformance. All of these tests fell short (11% each) of a benchmark set by AHRQ, which means that the organization needs to work strikingly to achieve the benchmark point set forth by the national bodies. The dashboard metrics data provided by MMC has several knowledge gaps and uncertainties. For example, uncertainty on the credibility of the data sources and limited knowledge of how the data were collected remains uncertain. Besides the lack of knowledge on the underlying factors that contributed to the performance gaps of these tests is another knowledge gap that requires further information to improve evaluation.    Consequences Not Meeting Prescribed Benchmarks There are several health implications and consequences when healthcare organizations fail to meet the prescribed benchmarks for diabetes care that, include regular checkups of HbA1c tests and eye and foot exams. Failure to meet the HbA1C benchmark can lead to poor glycemic control as patients and care providers will be unaware of the glycemic levels of diabetes patients. The uncontrolled glycemic levels may lead to the onset of diabetes-associated diseases, including heart diseases, neuropathy, kidney damage, and retinopathy. This will ultimately reduce patient safety and quality of care (Zaharia et al., 2019). Furthermore, failure to provide adequate education on diabetes care and treatment will lead to decreased patient satisfaction. Patients must be properly educated on performing eye and foot exams to meet the prescribed benchmarks at national and state levels. Non-compliance with the testing will erode trust in healthcare providers and the organization’s ability to provide the best treatments. The inability of healthcare organizations to meet established standards profoundly impacts healthcare organizations and teams. For instance, the financial implications may also occur due to higher hospital readmission rates, chronic care treatment, and increased length of hospital stays.  NHS FPX 6004 Assessment 1 Dashboard Metrics Evaluation Furthermore, failing to meet bars set by national health organizations and policies also impacts the healthcare organization’s reputation and may result in loss of accreditations or relevant sanctions. Healthcare professionals may face increased patient load due to poor diabetes control leading to work burnout and increased turnover rates (Kontoangelos et al., 2022). The assumptions on which this analysis is based include that prescribed benchmarks on diabetes have a great clinical impact on diabetes patients as their implementation improves the glycemic level and reduces diabetes-associated diseases. Furthermore, the analysis assumes that healthcare organizations must have adequate access to resources, including staff, protocols and guidelines, and technology to meet the prescribed standards of diabetes care. The Underperformance of the Benchmark Several diabetes benchmarks estimate diabetes care, including HgbA1c being the most crucial as this test measures the patient’s blood glycemic levels. The HgbA1c benchmark acts as a diagnostic guideline for healthcare professionals to identify and diagnose diabetes in patients to plan further care treatment for them. Unmonitored HgbA1c levels in diabetes patients lead to various health implications, such as neuropathy, kidney failure, retinopathy, and cardiovascular diseases. According to WHO, diabetes caused 1.5 million deaths, out of which 48% occurred before patients reached the age of 70 years (World Health Organization, 2023). A study describes that stringent adherence to the HgbA1c benchmark can reduce retinopathy by 67%, diabetic nephropathy by 54%, cardiovascular disease risk by 35%, and peripheral neuropathy by 60% (Kaiafa et al., 2020). Most of the patients are affected by the poor performance of this benchmark as timely diagnosis of diabetes is prevented, leading to uncontrolled glycemic levels. This ultimately results in poor health outcomes such as diabetes-associated diseases. Patients may need to amputate their lower extremities and administer insulin frequently, reducing their quality of life and safety (Déruaz‐Luyet et al., 2020). This brings a compelling opportunity for healthcare organizations to improve in meeting this benchmark as it impacts their performance. The underperformance of this benchmark will result in higher hospital readmission rates impacting organizational functionality and increasing financial costs, and staff burnout due to patient overload.   Improving professional performance by performing this benchmark can enhance the quality of care and better-quality performance as the reduction in