Systemic Problem That Contributes to Adverse Quality and Safety Outcomes

Systemic Problem That Contributes to Adverse Quality and Safety Outcomes

Falls are a major concern for healthcare facilities as they result in increased hospital stays, a reduction in patients’ quality of life, and prove costly to patients as well as healthcare facilities. A multi-disciplinary approach is needed for the prevention of falls. Injuries related to falls are the most common cause of death in persons aged 65 years and above. Mortality and injury rates increase dramatically for all genders across the different races for persons aged 85 years and above. However, males aged 85 and above are more likely to die than females (Burns & Kakara, 2018). Of the frequently reported adverse events, falls top the list among adult in-patients. Falls can be underreported; hence, injury reporting is more likely to be a consistent measure of quality compared to fall incidences. Therefore, hospitals should ensure care quality based on injury rates, not only fall rates.

Patients that have communication disabilities linked to voice, language, or speech impairment have three times the likelihood of fall risk. Research also shows that hearing impairment is a risk factor for falls, especially for older adults (Jiam et al., 2016). Communication disability can be acquired later in one’s life or maybe lifelong and refers to the ‘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” (Dolmage, 2014).

Specific Practice Changes That Will Improve Quality and Safety Outcomes

Nurse and Patient (and Patient’s Kin) Education: The AHRQ (2019) points out that nurse and patient education is one intervention among many that can significantly reduce the incidences of patient falls. In most hospitals, a patient fall prevention week is used in the promotion of fall prevention. During this week, different communication forms are undertaken, including the use of posters, lectures, and pamphlets that can inform hospital staff about the dangers of fall-related risk factors such as polypharmacy. Hospital newsletters can be used in disseminating information with safety education provided through internal TV channels set up in the patient’s rooms, which will help educate the patients and their kin on fall prevention while in the hospital. Educational initiatives ought to support the following interventions: educating patient families on fall prevention; frequently reminding older patients who have an altered mental state to make use of the call bell and request assistance; instituting the use of color-coded bracelets for fall alerts to clearly communicate the risk status of patients to the staff and also in identifying the fall risk patients; posting a fall risk alert sign on the door of every at-risk patient; hourly rounds; and using bed alarms and ensuring the beds are as low as possible.

Hourly Rounding

Fall-risk patients rely on the availability of nurses. When patients are assessed every hour, it helps in making them feel less apprehensive and safer. The four P’s are utilized in hourly rounding, and these stand for pain, potty, position, and possession. The four P’s aim at preventing patient falls as well as pressure injuries; ensure that a patient gets assistance on accessing the toilet; the patient is not unsupervised; is assisted in changing bed positions; has the level of pain assessed; and has easy access to tissues, water, and the call bell among other essentials.

Video Monitoring

This is a developing technology that can be very effective in preventing falls. Video monitoring entails the use of portable or in-room fixed cameras equipped with speakers. A trained technician is also needed to observe the patient directly from a remote location. The technician uses two-way communication and video feed in intervening when observing the behavior of the patients, which could be potentially dangerous. A case study carried out in 2013 at Denver Health showed that video monitoring prevented 57 falls. In 2015, Burton and Vento published their work revealing that when video monitoring is compared to the use of restraints and sitters, the former outperformed the latter or had equal benchmarks.

Prioritize Proposed Practice Changes

The top priority change will be an installation of a video surveillance system that will monitor patients at high risk of falls yet have communication impairment. The second change will be enhancing patient and nurse education. Although this is a common practice in hospitals (AHRQ, 2019), a healthcare facility can improve its communication by perhaps having specific icons that will easily communicate the message. The third priority is hourly rounding, another common strategy applied in healthcare facilities (AHRQ, 2019). Increasing the number of staff in a healthcare facility is likely to increase vigilance when it comes to preventing falls. However, the nurse staffing shortage is a nationwide concern even as organizations aim to remain profitable by hiring the bare minimum number of nurse staff.

How Proposed Practice Changes Will Foster A Culture of Quality and Safety

The video surveillance of patients who cannot communicate will help staff at the orthopedic ward to keep an eye on and react in the shortest time in case a patient is about to experience a fall. Also, surveillance will help the nursing staff to note the characteristic behavior of each patient that precedes a fall and mitigate this before it happens. For example, if a patient is observed to be restless before needing to use the bathroom and if such a patient has bladder incontinence and fumbles to hastily get out of bed which leads to falling, a nurse will be aware of this behavior and aid the patient before the fall happens; or assist the patient to the bathroom at regular times to avoid the fall incidences.

How A Particular Organizational Culture or Hierarchy Might Affect Quality and Safety Outcomes

The matrix structure combines elements from the divisional and functional models of organizational structures and is more complex (Ahmady, Mehrpour, & Nikooravesh, 2016). In this structure, staff are grouped into functional departments based on their specializations and then further separated into divisional projects. In the hospital setting, the fall prevention program will need to be first implemented in one department; specifically, the orthopedic department will be implemented in other departments based on its success after adjustments. The orthopedic department is one of the departments with higher records of fall incidences. This is especially so for elderly patients admitted to the department ward following hip or knee replacement surgeries. The successful implementation of the video monitoring system in the orthopedic department ward will pave the way for other departments experiencing high fall incidences to adopt the same.

Justify Necessary Changes with Respect to Functions, Processes, Or Behaviors, Specific to Your Organization

As mentioned, the video monitoring system is the top priority change that will be implemented. The standard measures of fall prevention are implemented in most hospital settings (AHRQ, 2019), but in this case, the target patients are those with communication impairment. The best way to help reduce fall incidences, in the opinion of this paper, is to set up a patient surveillance system for patients unable to communicate with caregivers. When a specialized technician and staff are designated to monitor this group of patients, there will be fewer incidences of falls, zero occasions where nursing staff erroneously ignore alarms from the patient’s rooms, and subsequent reduction in hospital costs in terms of time, number of nurses having to frequently check on the patient, and re-admissions or longer hospital stays following fall incidences.

References

Ahmady, G. A., Mehrpour, M., & Nikooravesh, A. (2016). Organizational structure. Procedia-Social and Behavioral Sciences, 230, 455-462.

AHRQ. (2019). Falls. https://psnet.ahrq.gov/primer/falls.

Burns, E., & Kakara, R. (2018). Deaths from falls among persons aged≥ 65 years—United States, 2007–2016. Morbidity and Mortality Weekly Report, 67(18), 509.

Burtson, P., & Vento, L. (2015). Sitter reduction through mobile video monitoring. Journal of Nursing Administration, 45(7/8), 1–7

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

Jeffers, S., Searcey, P., Boyle, K., Herring, C., Lester, K., Goetz-Smith, H., & Nelson, P. (2013). Centralized video monitoring for patient safety: A Denver Health Lean journey. Nursing Economics, 31(6), 298–306.

Jiam, N. T. L., Li, C., & Agrawal, Y. (2016). Hearing loss and falls: A systematic review and meta‐analysis. The Laryngoscope, 126(11), 2587-2596.

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

Systemic Problem That Contributes to Adverse Quality and Safety Outcomes

PART 1 of 4 part assignment – please see included Grading Rubric & Instructional Video
****************************************************************************************************************
OVERVIEW:
Write an analysis, 4–5 pages in length, of the gap between current and desired performance, with respect to the provision of safe, high-quality patient care.

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.
________________________________________________________________________________________
QUESTIONS TO CONSIDER:
Culture and process contribute to our ability to develop and sustain quality and safety in a health care organization. By exploring these topics, you can analyze where you may have gaps in practice that affect outcomes. In addition, organizations must create benchmarks for outcomes to determine whether they are meeting quality and safety goals.

Systemic Problem That Contributes to Adverse Quality and Safety Outcomes

– What does your organization measure, related to quality and safety, and why?
– Are there certain aspects of your organization’s culture and processes that support or hinder quality and safety?
– Is the organization meeting outcome measurement benchmarks?
– If not, how might you address those gaps in performance? What system could be developed to support a change to close a particular gap?

_____________________________________________________________________________________
ASSIGNMENT INSTRUCTIONS:
Your quality and safety gap analysis will provide the basis for the remaining assessments in this course.

Preparation
As a nurse leader, you are fully aware of the hazardous nature of health care and that organizations must continually seek to improve the quality and safety of the care they provide to patients. For this assessment, you will identify a systemic problem in your organization, practice setting, or area of interest associated with adverse quality and safety outcomes (for example, an increase in the incidence of falls or medical errors) and analyze the gap between current and desired performance.Requirements:
The requirements outlined below correspond to the grading criteria in the Quality and Safety Gap Analysis Scoring Guide. Be sure that your written analysis addresses each point, at a minimum. You may also want to read the Quality and Safety Gap Analysis Scoring Guide and Guiding Questions: Quality and Safety Gap Analysis (linked in the Resources) to better understand how each criterion will be assessed.Conducting the Analysis:

Systemic Problem That Contributes to Adverse Quality and Safety Outcomes

– Identify a systemic problem in your organization, practice setting, or area of interest that contributes to adverse quality and safety outcomes.

– Propose specific practice changes that will improve quality and safety outcomes and bridge the gap between current and desired performance.

– Prioritize proposed practice changes.

– Determine how proposed practice changes will foster a culture of quality and safety.

– Determine how a particular organizational culture or hierarchy might affect quality and safety outcomes.

– Justify necessary changes with respect to functions, processes, or behaviors, specific to your organization.

– Communicate analysis data and information clearly and accurately, using correct grammar and mechanics.

– Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.

Systemic Problem That Contributes to Adverse Quality and Safety Outcomes

– 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 analysis should be 4–5 pages in length, not including the title page and reference page.