PART I of III:  Analysis of Patient Safety and Quality of Services in a Hospital

Analysis of Patient Safety and Quality of Services in a Hospital – Healthcare quality has patient safety as the central them and overriding objective where all healthcare organizations in the US have to observe and pay more attention to the importance of having an established culture of safety (El-Jardali & Fadlallah, 2017)….

The assessment has three parts. Click each of the items below to complete this assessment.

Part I: Analysis of Patient Safety and Quality of Services in a Hospital

  • In an increasingly consumer-driven healthcare system that is focused on safety and quality of services, patients and healthcare professionals alike are able to access reliable data about the quality and safety records of organizations. Healthcare administrators can look at how their organizations are faring within specific categories and compare results with those of other institutions. As part of this Assessment, you will analyze this data to determine areas within a healthcare organization in need of additional improvement.
  • For this Assessment, select a hospital you work for or one that has been awarded the Baldridge Performance Excellence Award. In preparation for developing a patient safety plan, use data found on websites, such as the Leapfrog Group Hospital Safety GradeHospital Compare, maintained by the Centers for Medicare & Medicaid Services (CMS); and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Hospital Survey, to review the wide range of issue-specific data aligned to patient safety, quality of services, and patient satisfaction.
  • In a 1- to 2-page analysis:
    • Analyze three safety and quality results you found for the hospital such as: HCAHPS, pneumonia care, and emergency room treatment times.
    • Describe the process and procedure used to access the data including a description of at least two websites that provide the data used.

Part II: Failure Mode and Effects Analysis

  • Complete the FMEA (Failure Mode and Effects Analysis) Template, the fourth PDF under the \”Download Documents\” heading located at the bottom of the Institute of Healthcare Improvement website. To access the actual tool, you must complete an IHI registration (no cost). Use the tool to look for a weak link in the quality chain. Look beyond direct care for things that could contribute to the error. Think organizationally to trace the problem back to the original cause. Rate possible events that could go wrong.

Part III: Patient Safety Plan Proposal

  • Based on the results of Part 1 and Part 2, select three areas related to patient safety or quality in need of additional training or support. Then, create a 3- to the 5-page proposal in which you:
    • Design a patient safety plan to address three areas of focus from the results of the FMEA.
    • Describe an evaluation method to assess whether the patient safety plan is successful.

Solution

PART I of III:  Analysis of Patient Safety and Quality of Services in a Hospital

Healthcare quality has patient safety as the central them and overriding objective where all healthcare organizations in the US have to observe and pay more attention to the importance of having an established culture of safety (El-Jardali & Fadlallah, 2017). Like other healthcare facilities across the nation, Adventist Health White Memorial (AHWM), located in California, has invested in understanding the principles, attitudes, and standards to realize a culture of safety within the organization. It further incorporates attitudes and behavior that interlink with the expected and appropriate patient safety culture. The successful implantation of various strategic measures has seen the healthcare facility receive the coveted Baldridge Performance Excellence Award. As such, Part I of this essay purposes to analyze the hospital’s patient and quality of services by analyzing three safety and quality results found in the Leapfrog Hospital Survey and subsequent Leapfrog Hospital Safety Grade

Three Safety and Quality Results Found in Leapfrog

The Leapfrog Group has five domains that it uses to rate a healthcare facility, namely infections, problems with surgery, practices to prevent errors, safety problems, and doctors, nurses, and hospital staff. It is important to state that The Leapfrog Group is a nonprofit watchdog organization that endeavors to serve as the voice for consumers and purchasers of healthcare services by utilizing their combined influence to foster a positive transformation of the US healthcare system (Smith et al., 2017). The limited scope of this essay dictates that only three of the quality results will be highlighted.

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Analysis of Patient Safety and Quality of Services in a Hospital
Analysis of Patient Safety and Quality of Services in a Hospital

The first one is on healthcare quality with a specific focus on practices meant to prevent errors. Studies indicate that around 10%- 43% of patients in hospitals encounter medical errors, with approximately 1 to 4 out of every ten patients experience an adverse event. Under this domain, the Leapfrog Group has subdomains like doctors ordering medications through a computer where AWHM scored a hundred like the best hospital score. The score was realized in the handwashing domain, and staff works together to prevent errors. However, on the subdomain of safe medication administration, the AWHM score stood at 75 against the Best Hospital’s score of 100 and way below the average hospital’s score of 81.76(The Leapfrog Group, 2021). This means AWHM has to devise new strategies to resolve the issues related to medication administration. Likewise, the subdomain of communication about medicine and communication about discharge while slightly above the average hospital’s score of 77.53 with AWHM at 79 and 86.51 with AWHM at 87 was way below the Best Hospitals’ score.

            The second issue is on patient safety with a bias towards patients’ falls and injuries. The AWHM scores in the   Leapfrog Group Summer of 2021 report indicate the facility has to formulate effective measures focusing on addressing dangerous bedsores where it scores 0.97 against the average national hospital of 0.58 and the Best Hospital score of 0.03. The only plus in this domain was zero incident on air or gas in the blood, making it among the Best Hospital Score. Therefore, the management should employ similar inpatient falls and injuries strategies to have a zero event in this subdomain, the same with the Best Hospital Score.

`The third and last issue is patient experience with doctors, nurses, and hospital staff whereby it was reported that AWHM scored below the national average hospital score in the subdomains of communication with doctors at 90 against the AHS (Average Hospital Score) of 97, communication with nurses at 89 against the AHS of 96 and responsiveness of hospital staff at 84 against the AHS of 84.21. However, improvement in these subdomains can also be equated to the other three in this domain, where AWHM scores amongst the best hospital scores.

Description of the Process and Procedure Used to Access the Data

The website www.LeapfrogGroup.org collects, analyzes, and disseminates data to guide value-based purchasing. The hospitals voluntarily submit data to demonstrate their commitment to transparency while the grades are assigned through many sources. This means hospitals with available data are graded irrespective of whether they participated in the survey or not. The grades exclusively focus on safety issues, namely accidents, injuries, and errors. The second website where one can collect related data is www.hcahpsonline.org, which focuses on measuring patients’ perspectives on hospital care. In addition to concentrating on patient safety, HCAHPS Survey also delves into the quality of service and patient satisfaction. Data in this website is collected through basic sampling from eligible discharges monthly. Most importantly, the survey is administered in random samples of adult patients across all medical conditions within two days and six weeks post-discharge. The hospitals can either use an approved survey vendor or collect their HCAHPS data.

Part II of III: Failure Mode and Effects Analysis (FMEA)

The FMEA is a systematic and qualitative tool developed within a spreadsheet to assist providers in anticipating what might go wrong with a process or product in context. It, therefore, helps to identify potential problems and their effects. The criteria for an FMEA analysis utilize three parameters to assess a problem beginning with the severity of impact on the customer, how frequently the problem is likely to occur, and finally, how easily the problem can be detected. Only after ranking the severity, occurrence, and detention for each failure mode is the healthcare team able to calculate a risk priority number.

The table that follows outlines AWHM’s FME severity, occurrence, and detection ratings of the three issues identified in Part I.

Steps in the process What is the step?Failure Mode In what ways can the step Go wrong?Failure Causes What causes the step to go wrong?Failure Effects What is the impact on the patient if the failure mode is not prevented or corrected?Likelihood of occurrence (1-10) How Frequently is the cause likely to occur?Likelihood Of detection (1-10) How probable is the detection of the failure mode cause?severity   (1-10) How severe is the effect on the patient?Risk profile number Calculated as the product of severity* occurrence* detectionAction to Reduce Occurrence What are actions for reducing the occurrence of the cause or improving its detection?  
1 Quality  practices to prevent errorsDuring medical administration Writing out a prescription in ineligible handwriting  Or prescribing adult dosage to a childWriting in handwriting that is ineligible or using unfamiliar abbreviationsWrong medication administration may cause serious adverse effects, trigger allergic reactions, and even cause life-threatening complications4754*7*5= 140Use computerized physician Bar Code Medication Administration(BMCA) would alert the physician if the medication theyorder could cause harm
2 Patient safety issuesPatient falls and injuries Patients who are unable to walk properly  on their own  can fall off their bed or when going to the washroomsFailure to assist patients who cannot walk independently. Not assisting affected patients with walking aids.Serious patient falls can result in permit disability. Some falls can be fatal  368144Hospital staff to assist patients at risk of fall to use the washrooms or when walking around. Equip patient beds with alarms to alert staff if the patients want to go to the toilet.
3 Patient Experience with doctors, nurses, and hospital staffCommunication breakdown between the patient and the doctor or nurseNot considering patients’ perspectives on their care. Not responding to all patient questions or condescendingly treating the patient.Can lead to medical errors, Lead to mix-ups or misdiagnosis44580Encourage the physician or nurse to take time in communicating effectively, listening actively, answering the patient questions, and treating the patients in a respectful and courteous way

After the team has assessed all the failure modes, the FMEA list is then adjusted in descending RP order ad these are then used as the basis remedial measures. Limited resources necessitate the biggest problem to be prioritized at the taking. Once the priorities have been agreed upon, the team then generates appropriate corrective measures as captured in Part III of this essay.

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Analysis of Patient Safety and Quality of Services in a Hospital
Analysis of Patient Safety and Quality of Services in a Hospital

Part III of III: Patient Safety Plan Proposal

Using AWHM’s FME severity, occurrence, and detection ratingsas the basis of this patient Safety Plan Proposal the three issues guided by the RPN are patient falls and injuries(144) followed by medication administration (140) and improvement of effective communication between doctors and nurses and patients and the responsiveness of staff to patient requests.

At AWHM Hospital, patient falls are specific areas of interest because they comprise a leading cause of adverse events. The Center for Medicare and Medicaid stopped hospital reimbursement for care related to serious injuries emanating from patient falls (Fehlberg et al., 2017). Existing literature supports evidence-based practices and multipronged fall prevention measures. One of these interventions is patient education and their families. Suffice it to say that falling is a significant public health issue that may decrease the patient’s quality of life and, in some cases, even death. Among the elderly population aged 65 years and above, falls are among the top most common causes of hospital admissions and extended hospital stays. The United States Department of Health and Human Services promotes interest in fall prevention in Healthy People campaigns. The Healthy People 2020 and now Healthy People 2030 objectives seek to prevent accidental injuries to reduce falls and prevent hip fractures. In a hospital setting like AWHM, falls are a nursing concern. Haller et al. (2018) note that the Magnet Nursing Designation award indicates a high quality of nursing practice with Magnet Standards requiring that hospital staff monitor key nurse-based outcome indicators and compare the hospital’s performance for these outcomes a national benchmark. Currently, there exists an evidence-based fall prevention bundle availed by the Agency for Healthcare Quality. However, the bundle emphasizes including patient and family education on fall prevention without offering the most effective component in the education or delivery of the fall prevention bundle. These factors create a gap in the available evidence-based messages and the content for preventing patient falls.

In contrast, available resources attest to fall prevention targeting the elderly the nurses and hospital staff are not included in these, as do the patient’s family members and significant others(Heng et al., 2019). Subsequently, the proposed patient safety strategy is to design an evidence-based poster presentation education video on fall prevention among elderly inpatients.  The education intervention will incorporate the family member and hospital staff, execute teach-back with the patient and make a comparison of the difference in fall rates between patients and families in the control group (will not receive the expanded education)and the intervention group whose members will receive posters and take part I the development of the poster. A suitable individual health behavior theory will be selected to be the project’s theoretical framework. The theory of planned behavior and social support theory will be utilized.

The proposed education plan and training will use the three determinates of planned behavior. To have the patients develop a healthy attitude of all prevention strategies, they will need to understand the prevalence, negative impact, and associated risk factors of falling. These include non-modifiable factors like their advanced age, loss of balance, weakness medication, toileting, and time.  On the medication factor, the education component will include using the Bar Code Medication Administration to minimize medication errors, and the patient’s cognition factors will necessitate the introduction of measures to improve communication between the patient and the health care providers.  Improved communication will see the patients ambulating with or without assistance. The method used to evaluate the success of the proposed patient safety plan is that the patients will adopt the new fall prevention measures with the outcome measure being reduced or no incidences of fall with the hospital. Similarly, the effective use of BCMA will be measured to decrease or zero medication administration, while improved communication will be indicated by better patient satisfaction scores of their interaction with the doctor, use, or other hospital staff. In concise form, all four fall protection methods, fall elimination, fall prevention, fall arrest, and use of administrative controls, will be captured within the patient safety plan proposal.

References

El-Jardali, F., & Fadlallah, R. (2017). A review of national policies and strategies to improve health care quality and patient safety: a case study from Lebanon and Jordan. BMC health services research17(1), 1-13.

Fehlberg, E. A., Lucero, R. J., Weaver, M. T., McDaniel, A. M., Chandler, M., Richey, P. A., & Shorr, R. I. (2017). Impact of the CMS no-pay policy on hospital-acquired fall prevention-related practice patterns. Innovation in Aging1(3), igx036.

Haller, K., Berends, W., & Skillin, P. (2018). Organizational culture and nursing practice: the magnet recognition program® as a framework for positive change. Revista Médica Clínica Las Condes29(3), 328-335.

Heng, H., Jazayeri, D., Shaw, L., Kiegaldie, D., Hill, A. M., & Morris, M. E. (2019). Educating hospital patients to prevent falls: protocol for a scoping review. BMJ Open9(9), e030952.

 Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2021). Medical Error Reduction and Prevention. StatPearls [Internet]; StatPearls Publishing: Treasure Island, FL, USA.

Smith, S. N., Reichert, H., Ameling, J., & Meddings, J. (2017). Dissecting Leapfrog: how well do Leapfrog safe practices scores correlate with hospital compare ratings and penalties, and how much do they matter? Medical care55(6), 606.

The Leapfrog Group (2021Adventist Health White Memorial This Hospital’s Grade B Spring 2021URL: https://www.hospitalsafetygrade.org/h/adventist-health-white-memorial

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