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- Draft a 6-page report on outcome measures, issues, and opportunities for the executive leadership team or applicable stakeholder group.
Introduction
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.
As a nurse leader, you may be called upon to submit a detailed report to your executive leadership team and key stakeholders that describes a quality or safety problem and its effects on outcomes, fully supported by relevant and credible data.
This assessment provides an opportunity to draft such a report in which you can call attention to quality and safety issues and opportunities, effectively support your position, and lay out a plan for change.
This assessment is based on the executive summary you prepared in the previous assessment.
Preparation
Your executive summary captured the attention and interest of the executive leadership team, who have asked you to provide them with a detailed report addressing outcome measures and performance issues or opportunities, including a strategy for ensuring that all aspects of patient care are measured.
Note: As you revise your writing, check out the resources listed on the Writing Center’s Writing Supportpage.
As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.How might you engage stakeholders to help develop, implement, and sustain a vision to actually change and improve patient outcomes?
What arguments might be most effective in obtaining agreement and support?
What recommendations would you make to implement a proposed plan for change?
The following resources are required to complete the assessment.
Running head: OUTCOMES, ISSUES, AND OPPORTUNITIES 1
Outcomes Measures, Issues, and Opportunities
Kathryn Forsyth
Capella University
HealthCare Quality Safety Management
Outcome Measures, Issues, and Opportunities
July, 2020
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Outcome Measures, Issues, and Opportunities
Medication administration is a large part of care provided to patients during each shift.
Nurses must deal with multitasking, interruptions, chaotic environments, and maintain
professional quality care. The United States has between 7,000 and 9,000 medication error
related deaths each year (Tarig, Vashisht, & Scherback, 2020). Near misses and adverse events
can occur during any point during the medication process from orders, documenting,
transcribing, dispensing, administering, and/or monitoring (Tarig, 2020). Nurses have high
patient loads, increased responsibilities, need to be aware of health costs and ways to decrease
those costs. This report will address measurable patient outcomes, gaps that need to be addressed
and interventions that are available to improve patient safety.
The Agency for Healthcare Research and Quality (AHRQ) has defined patient safety as
“freedom from accidental or preventable injuries produced by medical error” (Agency for
Healthcare Research and Quality (AHRQ), N.D.). A Quality Interagency Coordination Task
Force was created by the Department of Health and Human Services and other federal agencies
has advised using teamwork is an important way to improve patient safety (Buljac-Samardzic,
Dekker-van Doorn, & Maynard, 2018). This interagency team provided an increased awareness
to the media which put a spotlight on an issue that many would have rather ignored. The group
has pushed to increase reporting of all adverse medical events (ADEs). By exposing the issues,
the agency has forced facilities to create new policies and procedures to reduce adverse events.
High-Performing Organizations
Doctors Hospital is a high performing facility with many awards for providing the best
care. This organization has a culture to encourage the staff communicate when they have an
opinion on a way to improve patient care. The administration and leaders use the Triple Aim
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Framework to evaluate the root cause of medication errors within the facility. The goal of Triple
Aim is to provide interventions to improve quality of healthcare. The interventions and goals are
used to improve patient outcomes, patient satisfaction, decrease errors, and reduce cost of
healthcare (American Hospital Association, 2015).
Initiatives focusing on patient-centered quality provides an analysis of the issues and how
to become a High Reliability organization and implement the Triple Aim framework. Both high
reliability and Triple Aim focuses on quality improvement initiatives to reduce and/or prevent
patient injury and improve safety. When using High Reliability and Triple Aim framework, the
facility is seeing quality interventions with improved patient outcomes, patient satisfaction, a
decline mortality rates, adverse events, and near misses (Bodenheimer & Sinsky, 2014). The use
of technology, specifically bar code scanning has decreased medication errors however the use of
technology should never replace nurses knowledge, competency, continued use of double
checking information for high risk medications and using the computer as the third check to
completed the triple check system. By encouraging a questioning attitude, the facility is
encouraging nurse to seek additional information on unfamiliar drugs and asking questions for
when the medication orders does not make sense for the patient’s diagnosis (Rodziewicz &
Hipskind, 2020). The implementation of the above initiatives has reduced the medication errors,
improved communication, and increased patient education on medications.
Doctors Hospital is working to address medication errors after each event is report.
Trying to address adverse events and near misses as a systemic approach is very difficult as there
are many different units in the facility and each unit high risk medications are not the same.
Nursing leaders encouraging self-reporting of adverse events or near misses has improved
communication between administration, leaders, and other staff. The use of non-punitive or
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retribution when reporting medication errors or concerns has built trust between all parties.
Leadership using medication errors as a learning opportunity instead of placing blame, will
increase the overall quality of care. Determining the root cause of the medication error to create
interventions to prevent the same error in the future is critical. Doctors Hospital received a grade
of “c” in 2017, in 2018 the grade was a “d”, and in 2019 the grade was a “b”. Per the Leapfrog
Group 2020 website, the issues with medication and patient safety are related to communication
about medications, discharge planning, and staff communication. Leapfrog automatically gives
the facility a 100 is they are using the barcode system, which is not indicative of adverse events
and near misses since this is int addressed. In 2018, the hospital developed initiatives, objectives,
and goals to improve their rating. The new score is now a “b” in 2020 which is attributed to
improved training, improved technology, encouraging expressing concerns and adverse events,
and creating multidisciplinary group to improve communication.
Outcomes Measured
Doctors hospital mission and vision include a commitment to the care and improvement
of human life. To strive to deliver high quality, cost effective healthcare by incorporating the
following value statements, to recognize the unique and intrinsic worth of each individual, to
treat everyone with compassion and kindness, act with absolute honesty, integrity and fairness in
our business and personal lives. Also, our colleagues are valuable members of our healthcare
team and vow to treat each other with loyalty, respect, and dignity (Doctors Hospital, 2020).
Leadership skills, communication, and trust is an integral part of change, the leader must
be able to lead, deal with conflict, inspire, and communicate effectively. The interventions,
objectives and goals must be clearly stated and defined for the staff so there is no
misunderstanding. Outcomes and culture are positively connected to leadership atmosphere and
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staff satisfaction with their jobs. Experienced staff that have been with the same facility for many
years has experienced changes in policies and procedures, shifts in vision and mission
statements, working through nursing shortages and improvement of quality measures. The lack
of leadership will lead to increase in stress in the work environment, increases the rate of failures
for new interventions, policies, procedures, and outcomes. Highly motivated leadership can
improve the work environment, increase adherence to new policies, procedures and intervention
therefore encouraging the staff to meet objectives and goals of the project.
Adding technology to include bar scanning, smart pumps, ability to research medication
at bedside to provide education and addressing look alike, sound alike drugs have decreased
adverse events and near misses. By adding technology, the facility has enabled the nurses to
provide a third check to use of medication which increases patient safety and quality of care. By
using High Reliability, we can focus on key elements to include providing better education to
staff, increase training for leadership, encourage a culture focused on safety and reduction of
medical errors (Chassin & Loeb, 2013).
Performance Issues and Opportunities
Medication errors are extremely costly for the organization and insurance carriers.
Almost 400,000 a year hospitalized patient has experienced preventable harm of some type. This
has resulted in approximately 100,000 deaths each year. This creates an extreme financial burden
that can cost up to $20 billion dollars. Errors may contribute to the death of a patient or cause
long term harm which can lead legal issues that will increase costs to the facility (Rodziewicz &
Hipskind, 2020).
Many errors are related to look alike, sound alike drugs, which is being dealt with by
each facility as well as drug companies. Facilities are encouraging staff to report these types of
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medications so the facility can come up with a plan to address the drugs and ways to differentiate
between them. One suggestion for drug manufactures is to use Tall Man lettering and color-
coding which aims to highlight the difference between two similar drugs by capitalizing part of
the drug names. Many organizations have endorsed Tall Man lettering including the Joint
Commission and the Institute for Safe Medication Practices (ISMP) (Larmené-Beld, Alting, &
Taxis, 2018). By encouraging voluntary reporting in a blameless, guiltless environment will lead
the facility to be able to investigate and determine the core issue and develop ways to prevent the
error in the future (Patient Safety Network, 2019).
After researching 2019 medication errors, the evidence shows there is an overwhelming
incorrect usage of the bar code scanning, only 30% of staff was using the system correctly.
Personally, I have scanned the bar code from the chart which led to making a medication error by
scanning the wrong bar code and giving the medication to the wrong patient. There are many
ways to override the system when alerts pop up, many nurses do not even read the alerts. One
way to address this is update the bar code system for the nurse to have to manually type a reason
why the alert is being overridden. This will impact time but will overall make the nurse more
accountable. Total numbers of errors on the 50 bed burn unit for 2019 was 6000. Total resulting
in injury was 600 and total deaths 15. In 2019, the average number of medical errors on the 50-
bed unit was sixteen per day, this seems high, however medication errors include the route,
dosage, time, patient, and medication. So many of these errors could be related to time and most
errors did not cause injury or death. The attached spreadsheet breaks down the errors in 2019 and
2020 by total errors per year, total errors resulting in injury, total errors resulting in death, and
correct use of bar code scanning.
Strategy Outline
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Nursing leadership plays a key role in implementation of change, encouraging quality
communication, and improving patient outcomes. Lack of strong leaders will ultimately lead to
failure of the initiative, objectives, and goals of the project. Barriers may inadvertently be placed
by administration, leadership, and other staff which may limit the nurse being able to provide
quality, cost efficient, safe care. Forces that can drive change in healthcare include cost, need of
specific treatments, high patient to staff ratios, ethics, values, code of conduct, and the drive to
improve patient outcomes and satisfaction (Salmond & Echevarria 2017). Use of change theory
for this report is useful as without a structured approach the initiatives and goals will fail.
Change theory includes Mr. Lewin’s use of unfreezing, moving, and refreezing. Unfreezing is to
identify the issues and assess need for change. Moving is the interventions needed for a plan to
be created and put into effect. Refreezing the plan is in place, the changes have been made and a
new normal is established (Cummings, Bridgman, & Brown, 2016).
Leading change is a challenge for leaders with the intricacies and challenges of ever-
changing health care environments to ensure quality patient care. Rogers’ Innovation Diffusion
Theory includes five stages include knowledge, persuasion, decision, implementation, and
confirmation (Udod & Wagner, 2018). Leaders using the change theory and the five steps of
Rogers’ theory will be able to ignite change, address strengths and weaknesses of the team,
encourage the team to incorporate interventions to achieve the goals. Leaders need to be able to
adapt and use multiple types of leadership theories, have excellent listening skills, and create a
welcoming environment to encourage open, honest communication, and defuse conflict.
For this project I believe I would use Rogers’ Innovation Diffusion Theory, the first stage
is knowledge, implementing new education on technology, the need for the change, and the
initiatives, objectives and goals would be reviewed. This would encourage everyone to be ready
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for the change. The leaders would want to address the strengths and weakness of the staff, by
determining the staff that area already using the bar code system correctly so they can pair up
others who are not for mentoring. The idea would be to use the strength of some to overcome the
weakness of others with mentoring, peer reviews, and encouragement, this would be part of the
persuasion step. The third step is the decision, which is when the interventions are decided upon,
when the project will start. Fourth step is to implement the interventions and lastly would be to
confirm the interventions are moving the staff towards the goals set.
By implementing additional teaching on use of bar scanning system, updating the
technology to force the nurse to address the reason when the system alerts, adding triple checks
to high risk medications, encouraging nurses use Wi-Fi to address any medication they need
education on and provide that education to the patient and reporting of look alike, sound alike
drugs so the pharmacist can tag those drugs with an additional alert. By implementing these
initiatives, the 2020 data shows a 50% reduction in medication errors, errors resulting in injury
are down 66%, injury resulting in death is down 66% and correct use of bar code scanning has
improved by 60%. Please see attached spreadsheet to review the past six months and see how the
initiatives implemented has reduced errors per month.
Proposed plans will be shared with all stakeholders either in a staff meeting or
electronically. During the group presentation, the need for change will be addressed,
interventions, objectives, and goals will be shared. Everyone present will be given an opportunity
to review the written material, ask questions and express concerns or ideas.
Conclusion
Medication errors have always been an area we can all improve on, use of technology
with bar code scanning, smart pumps, and the ability to research drug information at the bedside
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has reduced errors. Healthcare is an ever-changing environment; we must learn to change and
initiate policies and procedure to improve patient safety. Striving to reduce near misses and
adverse events will be a goal for every facility. We must work together to improve safety and
patient outcomes by being more diligent when administering medications.
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References
Agency for Healthcare Research and Quality. (n.d.a). Patient safety.
https://psnet.ahrq.gov/glossary?glossary%5B0%5D=term%3AP
American Hospital Association. (2015). Care and payment models to achieve the Triple Aim.
Retrieved from https://www.aha.org/ahahret-guides/2016-01-26-care-and-payment-
models-achieve-triple-aim-0#:~:text=Hospitals%20and%20health%20care
%20systems,designing%20new%20care%20delivery%20systems.
Bodenheimer, T and Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the Patient
Requires Care of the Provider. The Annals of Family Medicine, 12 (6) 573-576; DOI:
https://doi.org/10.1370/afm.1713
Buljac-Samardzic, M., Dekker-van Doorn, C., & Maynard, M. T. (2018). Teamwork and
teamwork training in health care: An integration and a path forward. Group &
Organization Management, 43(3), 351-356. doi:10.1177/1059601118774669
Chassin, M., & Loeb, J. (2013). High-reliability health care: getting there from here. The
Milbank quarterly, 91(3), 459–490. https://doi.org/10.1111/1468-0009.12023
Cummings, S., Bridgman, T., & Brown, K. G. (2016). Unfreezing change as three steps:
Rethinking Kurt Lewin’s legacy for change management. Human relations, 69(1), 33-60.
Doctors Hospital. (2020). Mission and Vision. Retrieved from https://doctors-
hospital.net/about/mission-and-vision.dot
The Leapfrog Group. (2020). Hospital Safety Grade. Retrieved from
https://www.hospitalsafetygrade.org/h/doctors-hospital-of-augusta?
findBy=hospital&hospital=Doctors+Hospital+of+Augusta&rPos=237&rSort=grade
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Larmené-Beld, K.H.M., Alting, E.K. & Taxis, K. (2018). A systematic literature review on
strategies to avoid look-alike errors of labels. Eur J Clin Pharmacol 74, 985–993.
https://doi.org/10.1007/s00228-018-2471-z
Patient Safety Network (PSA). (2019). Medication Errors and Adverse Drug Events. Retrieved
from https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
Rodziewicz L., Hipskind J. (2020). Medical Error Prevention. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK499956/
Salmond, S. W., & Echevarria, M. (2017). Healthcare Transformation and Changing Roles for
Nursing. Orthopedic nursing, 36(1), 12–25.
https://doi.org/10.1097/NOR.0000000000000308
Tariq, A., Vashisht, R., Scherbak, Y. (2020). Medication Errors. StatPearls Publishing. Retrieved
from: https://www.ncbi.nlm.nih.gov/books/NBK519065/
Udod, S., & Wagner, J. (2018). Common Change Theories and Application to Different Nursing
Situations. Leadership and Influencing Change in Nursing.
Upadhyay, S. (2020). Keeping patients safe: How has the patient safety movement evolved in the
U.S.? Patient Safety & Quality Healthcare. Retrieved from
https://www.psqh.com/analysis/keeping-patients-safe-how-has-the-patient-safety-
movement-evolved-in-the-u-s/
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Draft a 6-page report on outcome measures, issues, and opportunities for the executive leadership team or applicable stakeholder group. Introduction
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. As a nurse leader, you may be called upon to submit a detailed report to your executive leadership team and key stakeholders that describes a quality or safety problem and its effects on outcomes, fully supported by relevant and credible data. This assessment provides an opportunity to draft such a report in which you can call attention to quality and safety issues and opportunities, effectively support your position, and lay out a plan for change. This assessment is based on the executive summary you prepared in the previous assessment.
· Preparation Your executive summary captured the attention and interest of the executive leadership team, who have asked you to provide them with a detailed report addressing outcome measures and performance issues or opportunities, including a strategy for ensuring that all aspects of patient care are measured.
·
Note: As you revise your writing, check out the resources listed on the Writing Center’s
Writing Support
page. As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.
· How might you engage stakeholders to help develop, implement, and sustain a vision to actually change and improve patient outcomes?
· What arguments might be most effective in obtaining agreement and support?
· What recommendations would you make to implement a proposed plan for change?
· The following resources are required to complete the assessment.
·
APA Style Paper Tutorial [DOCX]
. Use this for your report.
· Requirements
Note: The requirements outlined below correspond to the grading criteria in the Outcome Measures, Issues, and Opportunities Scoring Guide. Be sure that your written analysis addresses each point, at a minimum. You may also want to read the Outcome Measures, Issues, and Opportunities Scoring Guide and
Guiding Questions: Outcome Measures, Issues, and Opportunities [DOCX]
to better understand how each criterion will be assessed. Drafting the Report
· Analyze organizational functions, processes, and behaviors in high-performing health care organizations or practice settings.
· Determine how organizational functions, processes, and behaviors affect outcome measures associated with the systemic problem identified in your gap analysis.
· Identify the quality and safety outcomes and associated measures relevant to the performance gap you intend to close. Create a spreadsheet showing the outcome measures.
· Identify performance issues or opportunities associated with particular organizational functions, processes, and behaviors and the quality and safety outcomes they affect.
· Outline a strategy, using a selected change model, for ensuring that all aspects of patient care are measured and that knowledge is shared with the staff.
· Writing and Supporting Evidence
· Write coherently and with purpose, for a specific audience, using correct grammar and mechanics.
· Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.
· Additional Requirements Format your document using APA style.
· Use the
APA Style Paper Tutorial [DOCX]. 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 report should be 6 pages in length,
not including the title page and reference page.
· Add your Quality and Safety Outcomes spreadsheet to your report as an addendum.
·
Portfolio Prompt: You may choose to save your report to your
ePortfolio
.
·
· RUBRIC Competencies Measured By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
· Competency 1: Analyze quality and safety outcomes from an administrative and systems perspective.
· Identify typical quality and safety outcomes and their associated measures.
· Competency 3: Determine how specific organizational functions, policies, processes, procedures, norms, and behaviors can be used to build reliability and high-performing organizations.
· Analyze organizational functions, processes, and behaviors in high-performing organizations.
· Determine how organizational functions, processes, and behaviors support and affect outcome measures for an organization.
· Identify performance issues or opportunities associated with particular organizational functions, processes, and behaviors and the quality and safety outcomes they affect.
· Competency 4: Synthesize the various aspects of the nurse leader’s role in developing, promoting, and sustaining a culture of quality and safety.
· Outline a strategy for ensuring that all aspects of patient care are measured and that knowledge is shared with the staff.
· Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
· Write coherently and with purpose, for a specific audience, using correct grammar and mechanics.
· Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.
·
