dentify a health service quality improvement that you have been involved in or would like to see implemented.
Refer to the Structure/Process/Outcome approach to quality improvement. Identify two structures, two approaches, and two outcomes for your selected quality improvement.
In the post-acute setting, the reduction of falls is a common quality improvement project. The Center for Medicare and Medicaid Services has identified falls and falls with major injury as a standard Quality Measure that can affect the 5 Star Rating of a post-acute facility. As a director of nursing, I have developed many fall reduction quality improvement projects for a variety of facilities across the United States. I will share the structure, process, and outcomes of a fall reduction program I have recently implemented in my own facility.
It is common clinical knowledge that a decrease in the quality and length of hours of sleep can increase confusion in the elderly. For this program, I sought to increase hours of sleep by changing the standard of practice of providing incontinence care every two hours at night for incontinent residents in post-acute. The structure of this program involved the re-education of all NAC and LN staff to a new goal of increasing sleep. The NAC for this project were educated on how to make slight changes in body position without waking a sleeping resident to decrease the risk of skin breakdown. The number of NAC staff required on the NOC shift was reduced from 5 to 4.
The process of implementation included changing from standard briefs to overnight briefs for all incontinent residents. These briefs are purchased at a higher price point but allow for increased length of time between incontinence changes allowing the resident to sleep longer. The policy and procedure for the standard of care related to incontinence were revised from q 2-hour incontinence changes to 2x a shift changes giving the average resident 6-8 hours of uninterrupted sleep. The policy was reviewed and compared to current regulation and CMS standards.
The outcomes far exceeded expectations. In a year-over-year and month-over-month comparison, the reduction of falls averaged 40% from January 2021 to January 2022. The number of falls with major injury was reduced by 80% in a year-over-year comparison. INs addition to a reduction of falls, the BIMS scores of 18 long term care residents increased by 5 points showing an increase in overall cognition that can be attributed to the reduction of staff interruptions of sleep. This one year fall reduction program shows great promise in changing the standard of care practice in the post acute environment.
This was a very interesting post regarding the reduction of falls. You provided two very good processes that can positively influence this health service quality. Two other processes that can also be implemented are the use of purewicks or condom caths in which some patients wake themselves up after an incontinence episode. This process would keep patients asleep during the night and would decrease confusion in the elderly and reduce falls. Another process would be adjusting medication schedules to fit the day and night schedule of the patients. This can include multiple different examples such as giving sleeping/relaxant medications at night so that patients don’t nap throughout the day and giving diuretics during the daytime so the patients will not be up urinating all night. These two additional processes can help reduce the risk of falls by providing more hours of rest to these patients. Thank you so much for sharing!
Quality initiatives are applied to processes within an institution or to a process of production to improve quality. eMAR systems and medication administration are wonderful methods used to streamline and assist patient care, however, sometimes there leaves something to be desired since the computer system is only comprehensive to a point. Using structure-process-outcome we can identify pitfalls, educate staff and improve this problem. Structure is considered resources used (Hicks, 2021). In this situation, we’ll refer to nurses and staffing as being part of the structure. These two parts of the structure go hand in hand. If nurses are lacking and a patient assignment is heavy has a result, mistakes can be easily made no matter how easy the eMAR system is to use because of stress and human error regardless of the training the nurse has received. Moving on to process, the activities involved are the actual activities involved in performing care. Considering medication administration, there is commonly a breakdown in communication between providers as well as transposing orders. Not only are orders transposed incorrectly, especially in long term care there is a high prevalence of duplicate orders. The eMAR system as well as the pharmacy associated with the institution should have double-checks in place to ensure orders are transposed correctly and the nurse should read-back an order to physicians or clarify if the physician is present to ensure accurate administration. However, related to general human error or in education, mistakes can still be made. Lastly, outcomes are the consequences of care (Hicks, 2021). Medication errors can cause detrimental effects on patients and family members if the error is severe enough. Ultimately, the proposed outcomes are increased patient satisfaction related to decrease in medication error and streamlined care by nursing staff, as well as decrease in duplicate orders from education of staff members and compliance with the eMAR system double-check process.
Hicks, L. L. (2021). Economics of Health and Medical Care. Jones & Bartlett Learning.
I like the different aspect that you shared in your discussion about using structure-process-outcome approach as a risk analysis. Electronic documentation including eMAR as a structure is a great addition to health care. Some of the pitfalls lies between the structure and the process which includes inadequate training/education to staff, noncompliant of the staff, electronic glitch and like you mentioned the inevitable human error. Like I mentioned in my other response, I currently work in a level 1 trauma ED setting. We use eMAR called EPIC systems and it has prevented a lot of medication error when used as designed. Despite that there are few times some of the errors are as a result of glitch but the outcome outweighs pre-eMAR era when compared.
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