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An Executive Summary of the Relevant Outcome Measures

An Executive Summary of the Relevant Outcome Measures

Key Quality and Safety Outcomes

Patient falls are among the leading causes of adverse events in hospital settings (AHRQ, 2019). Hospitals take diverse measures to ensure that patients remain safe by mitigating the causes of falls. The healthcare facility in this project is one such place where different measures are in place to minimize fall incidences. Among the measures put in place are frequent rounds, call alarms, lowering the patients’ beds, armbands that identify patients at risk of falls, and hanging door signs to alert staff of high-risk patients. However, what has remained a problem is the fall rates among patients who are unable to communicate. Despite this category of patients having call bells, they are unable to communicate due to their medical conditions. Additionally, nurses at the healthcare facility have reported having alarm fatigue and tend to ignore these particular patients. Sometimes the alarm fatigue has proven catastrophic when nurses later attend to a patient only to find them injured on the floor. Balancing between ignoring false alarms and attending to genuine call alarms in an ever-busy healthcare facility has been an ongoing challenge.

The project proposes installing video surveillance in rooms of patients at high risk of falling yet unable to communicate effectively. As mentioned in the previous section of this assignment, patients with communication disabilities linked to voice, language, or speech impairment are three times the likelihood of fall risk. Research also shows that hearing impairment is a risk factor for falls, especially for older adults (Jiam, Li, & Agrawal, 2016). By installing video monitoring equipment in the orthopedic ward, a technician will monitor patients 24/7. The orthopedic ward will be the pilot ward, and the success of the video monitoring in this ward will pave the way for the same to be repeated in other wards. When high-risk patients are monitored, nurses will attend to them when necessary, which is expected to bring some benefits. For starters, nurses will no longer have to deal with alarm fatigue as the technician will quickly report any false alarms and inform on genuine ones as well. Patient fall rates are expected to decline, and with that, a decrease in the amount of time that patients spend in admission wards; the hospital costs will decrease because of a decrease in patient length of stay, and there will also be a decline in injuries that often accompany falling. Lastly, the hospital will enhance its brand image and draw more clients because of unparalleled service delivery.

The Strategic Value to an Organization of Specific Outcome Measures

Falls have a significant impact on not only the patient but also the organization as well. Falls are a reflection of system failures in its processes and structure. Costs resulting from patient falls have been estimated to range between 0.85 and 1.5 percent of the total expenses in healthcare in the US, UK, EU, and Australian Kingdom (Cangany et al., 2015). According to WHO (2018), these financial costs are in addition to the other costs incurred, including damage to the patients and their kin and mistrust that is built toward the healthcare system. Therefore, the healthcare facility where the change project will be implemented will seek to eliminate avoidable falls among patients unable to communicate.

When the healthcare facility prevents falls, it will avoid costs, according to the Joint Commission. The Centers for Medicare and Medicaid Services (2018), reimbursements for inpatient falls are no longer extended to the healthcare facility. Non-refund is in line with CMS value-based payment initiative. This means that the healthcare facility now needs more than ever to concentrate on preventing falls from a patient safety as well as a financial perspective. The healthcare facility will have a better brand image, fewer costs, and more savings from a decline in fall rates, such as zero litigation fees and longer patient stays at the hospital ward. A decline in fall rates will mean better patient outcomes as patients will focus on recovering from the existing medical condition rather than injuries sustained from falls. Lastly, when the healthcare facility keeps a track record of zero fall rates, it can market itself as the safest hospital focusing on patient safety and quality, empathetic care.

The Relationships Between aSystemic Problem in My Organization/Practice Setting and Specific Quality and Safety Outcomes

At the healthcare facility where the project will be implemented, there is a system to ensure that fall rates are kept at the least possible numbers if not eliminated completely. As mentioned earlier, the healthcare facility has other systems in place to minimize fall rates, but these have proven to be ineffective when it comes to patients unable to communicate. Communication disability, according to Dalmage (2014) has defined communication disability as ‘impairments, activity limitations, and participation restrictions that affect an individual’s ability to interact and engage with the world in ways that are meaningful to them and those they communicate with” At the healthcare facility, patients with communication disability tend to be the ones that significantly contribute to alarm fatigue. Because these patients persistently ring the call bell, nurses often ignore them, but, in some cases, it has proved catastrophic. Also, because some of the patients, such as those with dementia, cannot remember the instructions given to them by nurses, they will forget to ring the call bell, while some are stubborn and want to remain independent by not asking for assistance. These patients end up falling from their beds or falling while walking toward the bathroom with no assistance, among others. Needless to say, and more so, orthopedic patients get injured, which increases their length of stay at the healthcare facility. The hospital is constantly at risk of litigation suits and complaints from patients’ kin, which negatively reflects the organization. Despite frequent nursing rounds to patients identified as high fall risk patients, the fall rate is still unimpressive.

How Specific Outcome Measures Support Strategic Initiatives Related to a Quality and Safety Culture

The project, in general, is a precursor to a bigger strategy; the success of the project in the orthopedic ward will pave the way for the same to be implemented in wards with similar patient characteristics. The orthopedic ward is selected because a majority of its patients are elderly patients admitted for hip replacement, knee replacement, and other orthopedic complications recovery. Some elderly patients become disoriented and delusional because of age and poly-pharmacological effects. Some are already admitted with existing comorbidities such as dementia, and containing these patients become a challenge.

As mentioned in the previous section of this assignment, the proposed change is the implementation of video monitoring. This will entail the use of portable or in-room fixed cameras equipped with speakers. A trained technician will observe the patient directly from a remote location. The technician will use two-way communication and video feed to intervene when observing the patient’s behavior, which could be potentially dangerous. The video monitoring post will be handled 24 hours, and the technician will communicate directly with the nurses on duty when any behavior by the patient suggesting imminent falling is observed. Video monitoring is expected to be effective in reducing incidences of patient falls in the orthopedic ward.

The specific outcome measure in this project will be a decline in the number of falls in the orthopedic ward among patients with a communication disability. The fall rates at the end of one month after the project is implemented will be compared against the average number prior to the project implementation. The numbers are expected to decline after video monitoring is implemented. Another dimension that will be measured is nurse satisfaction with the new system. Nurses currently have reported to be reeling from years of alarm fatigue. After a month following the change implementation, nurses working in the orthopedic ward will be requested to fill out a questionnaire giving feedback on their experience with the new monitoring system. The nurses will also be required to attend a one-day per week, one-hour-long session where they will brainstorm on the progress of the implementation. The brainstorming sessions will run for the first four weeks, after which they will fill out their feedback questionnaire. The brainstorming sessions are expected to be productive enough to bring changes to the system to fit in with the practical recommendations the nurses make. At the end of the month’s sessions, the system should be refined to run as effectively and efficiently as per the nurses’ recommendations and for reproducibility in other hospital departments, as discussed earlier.

How the Leadership Team Would Support the Implementation and Adoption of Proposed Practice Changes Affecting Specific Outcomes

The leadership team needs to adopt a hands-on strategy for this project. Leading by presence and example will be needed. Communication from and to the leadership will need to be open and honest and be frequent and timely. Communication, in this case, means guidance as the project unfolds and feedback on what works and what does not work.

With every change comes the possibility of rebellion. Some team members may be negative toward the proposed change and may even attempt to sabotage the same. To ensure that such employees do not derail the project’s progress, the leadership team will need to make it clear that anyone attempting to deter the changes will be dealt with in a disciplinary manner. However, before it comes to this, the management will need to have prepared and informed the team of the inevitable change and sold its benefits to the employees. Getting employee buy-in will make the project implementation run on the course and assure management that the employees will do as much as possible to ensure the project is successful.


AHRQ. (2019). Falls. Retrieved from

Cangany, M., Back, D., Hamilton-Kelly, T., Altman, M.S., Lacey, S. (2015). Bedside nurses leading the way for falls prevention: An evidence-based approach. Crit. Care Nurse, 35, 82–84.

Dolmage, J. T. (2014). Disability rhetoric. Syracuse University Press.

Jiam, N. T. L., Li, C., & Agrawal, Y. (2016). Hearing loss and falls: A systematic review and meta‐analysis. The Laryngoscope126(11), 2587-2596.

The Joint Commission. (2018). Physician leader.

World Health Organization (WHO). (2018). Falls. WHO: Geneva, Switzerland.


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An Executive Summary of the Relevant Outcome Measures

PART 2 of 4 part assignment
Write an executive summary, 4–5 pages in length, of existing outcome measures related to a performance issue uncovered in your gap analysis that you intend to address.

Note: Each assessment in this course builds on the work you completed in the previous assessment. Therefore, you must complete the assessments in this course in the order in which they are presented.

It has been said that time is money. In planning change to positively influence outcomes, it is important that you be able to quickly and concisely articulate your ideas. An executive summary is a short document that summarizes a more in-depth report. Think of it in terms of a public service announcement or commercial in which you must grab the attention of the stakeholders in order for your project to become a priority.

An executive summary enables you to provide the executive-level leaders with a brief but effective overview of what you have determined is a need, a change, or an enhancement for the organization. A succinct, informative summary linked to the organization’s strategic plan will improve your chances of obtaining stakeholder support.
Building stakeholder support is crucial to fostering and sustaining change. Therefore, as you approach this assessment, think about the stakeholders whose support you will need for the change you want to bring about.

  • – What information is most essential for both the formal and informal stakeholders to understand about the proposed change?
  • – How might you communicate the need for change using just a few sentences (this is often referred to as an “elevator speech”).

ASSIGNMENT INSTRUCTIONS: **Please see Grading Rubr8c**

Your summary of relevant outcome measures is based on your findings from the quality and safety gap analysis you completed in the previous assessment.

Your analysis of the gap between current and desired performance was the first step toward improving outcomes. You now have the information you need to move forward with proposed changes. Your next step is to focus on existing outcome measures and their relationship to the systemic problem you are addressing. For this assessment, you have been asked to draft a summary of existing outcome measures for your organization’s executive team to raise awareness of the problem and the strategic value of existing measures.Requirements:
Note: The requirements outlined below correspond to the grading criteria in the Executive Summary Scoring Guide. Be sure that your written analysis addresses each point, at a minimum. You may also want to read the Executive Summary Scoring Guide and Guiding Questions: Executive Summary (linked in the Resources) to better understand how each criterion will be assessed.Composing the Executive Summary:

  • – Explain key quality and safety outcomes.
  • – Determine the strategic value to an organization of specific outcome measures.
  • – Analyze the relationships between a systemic problem in your organization or practice setting and specific quality and safety outcomes.
  • – Determine how specific outcome measures support strategic initiatives related to a quality and safety culture.
  • – Determine how the leadership team would support the implementation and adoption of proposed practice changes affecting specific outcomes.

Writing and Supporting Evidence:

An Executive Summary of the Relevant Outcome Measures

An Executive Summary of the Relevant Outcome Measures

  • – Write clearly and concisely, using correct grammar and mechanics.
  • – Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.

Format your document using APA style. **** 7th Edition****

  • – Use the APA Paper Template linked in the resources. Be sure to include:
    • A title page and reference page. An abstract is not required.
    • A running head on all pages.
    • Appropriate section headings.
    • Properly-formatted citations and references.
  • – Your summary should be 4–5 pages in length, not including the title page and reference page.

The resources provided here are optional. You may use other resources of your choice to prepare for this assessment; however, you will need to ensure that they are appropriate, credible, and valid. The MSN-FP6212 Health Care Quality and Safety Management Library Guide can help direct your research, and the Supplemental Resources and Research Resources, both linked from the left navigation menu in your courseroom, provide additional resources to help support you.

An Executive Summary of the Relevant Outcome Measures

An Executive Summary of the Relevant Outcome Measures

Writing Executive Summaries

The following resources will help you in writing your executive summary.

Executive Summary Examples

The following documents provide examples of how various executive summaries are written.

Strategic Planning

The following resources will help you in addressing the strategic value of existing outcome measures.

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