NSG 601 Root Causes and the Use of Evidence

NSG 601 Root Causes and the Use of Evidence

NSG 601 Root Causes and the Use of Evidence

It is important to remember that medical errors of all types do not occur due to one person’s actions, but exist within the mindset of a deficiency that continues to prevail systematically (Institute for Healthcare Improvement, 2020). Having this mindset instead of personal blame allows for the confidence to identify and pursue system improvement. There are situations that do involve the individual personal; however, it is better suited to advance the overall quality of patient care. The beginning part of this process is identifying the quality gap. The quality gap consists of an identifiable lack in healthcare delivery perpetrated by a system that is flawed (Ogrinc et al., 2018). There are numerous quality gaps within the healthcare system and continue to be a problem regardless of the existence of interventions based on evidence-based practice.

The Joint Commission has made the use of root cause analysis (RCA) mandatory in regards to sentinel events and improving patient safety (Black, 2019). Healthcare acquired pressure injuries (HAPI) remains a top initiative for quality improvement and patient care. Black (2019) examined RCA and HAPI to introduce an organized approach in facilitating policy and procedure. An important element consists of the development of a designated team that includes a person with advanced knowledge of the subject matter such as a wound care nurse (Black, 2019). Including persons with advanced knowledge enhances the ability to understand the progression of the focused element. Black (2019) discusses the importance of identifying the start time for pressure injuries to provide clarification on HAPI. The article continues with discussions regarding the RCA including the process of care and identifying the quality gap, determining economic aspects of implementation of changes, development of policies, and education resources.

 

References:

Black, J. M. (2019). Root cause analysis for hospital-acquired pressure injury. Journal of Wound, Ostomy and Continence Nursing 46, (4), 298-304. https://doi.10.1097/WON.0000000000000546

Institute for Healthcare Improvement. (2020). Root cause analyses and actions. https:/www.education.ihi.org

Ogrinc, G. S., Headrick, L. A., Barton, A. L., Dolansky, M. A., Madigosky, W. S., Miltner, R. S. (2018). Fundamentals of health care improvement: A guide to improving your patients’ care (3rd ed.). Joint Commission Resources, Inc.

One quality improvement initiative that should be addressed within my workplace would be the use of a standardized communication tool between nurses during patient transfer. Currently, the standard of work during hand off report between nurses involves giving a verbal report to the receiving nurse. There are currently two policies regarding hand off and patient transfers at this facility. The policies, however, do not state that certain hand off communication tools should be used. At times, it is noticed that certain nurses may not relay pertinent patient information during patient transfer. Because of this, the quality gap may affect patient safety. This quality gap would be important to address because of its direct impact on patient care and safety. Some root causes for this gap in care are lack of education and guidelines regarding the topic.

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One research article that was interesting to review was a study conducted by Stimpson et al. (2020). Stimpson et al. (2020) found that nurses throughout a hospital understood patient hand-offs differently which resulted in handoff errors across departments. Because of this, a interdepartmental hand-off tool was implemented. Stimpson et al. (2020) found that improvements were seen in reported patient safety events after the implementation of the tool. It was also found that nurse satisfaction increased after the implementation (Stimpson et al. 2020). This study and implementation provided evidence that a standardized communication tool would be beneficial for nurses during patient transfer.

After reviewing the Institute of Healthcare Improvement module regarding Root Cause Analysis, it would be

NSG 601 Root Causes and the Use of Evidence
NSG 601 Root Causes and the Use of Evidence

important to address this quality improvement initiative to prevent a catastrophic event for patients. Hand off report is incredibly important regarding patient safety. If pertinent patient information is not given during patient transfer, then a patient may be harmed. This could be a minor to a catastrophic event (Institute for Healthcare Improvement, 2020). Because of this, it would be important to conduct a root cause analysis, implement a standardized hand off communication tool, and ensure the tool is being utilized. This in return promotes patient safety.

References

Institute for Healthcare Improvement. (2020). Root cause analyses and actions. https:/www.education.ihi.org

Stimpson, M., Carlin, K., & Ridling, D. (2020). Implementation of the m-lSHAPED tool for nursing interdepartmental handoffs. Journal of Nursing Care Quality35(4), 329–335. https://doi-org.ezproxy.snhu.edu/10.1097/NCQ.0000000000000451 (Links to an external site.)

I enjoyed reading your post. I agree with you that patient hand off communication is very important and it is a quality improvement that needs to me addressed in many hospital settings. Poor hand off communication between the nurses and treatment team can contribute to poor patient care and potentially jeopardize patient safety.  A standardized communication tool would be very effective. Quality improvement is essential in transforming organizational processes. Most healthcare organizations are involved in the quality improvement processes to ensure effective and quality patient outcomes. In healthcare systems, quality improvements refer to the framework mostly applied to systematically improve different healthcare delivery processes. In most cases, quality improvement processes ought to have characteristics that are measurable. Adjustment of communication processes is necessary in ensuring efficiency in the operational processes (McIlvennan et al., 2015). Effective communication structure can eliminate different errors associated with the delivery of quality healthcare services.  The integration of the standardized communication tools is critical in the transformation different healthcare processes (Azzolini et al., 2019). From the analysis of the article provided, there are different possible gaps that can be solved to improve the implementation of communication processes. The study article conducted by Stimpson et al. (2020). Stimpson et al. (2020) provides evidence that poor hand off communication can result in patient care errors which is something we should strive to avoid as much as possible.

References

Stimpson, M., Carlin, K., & Ridling, D. (2020). Implementation of the m-lSHAPED tool for nursing interdepartmental handoffs. Journal of Nursing Care Quality35(4), 329–335. https://doi-org.ezproxy.snhu.edu/10.1097/NCQ.0000000000000451 (Links to an external site.)

McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation, 131(20), 1796–1803. https://doi.org/10.1161/CIRCULATIONAHA.114.010270 (Links to an external site.)

Azzolini, E., Furia, G., Cambieri, A., Ricciardi, W., Volpe, M., & Poscia, A. (2019). Quality improvement of medical records through internal auditing: a comparative analysis. Journal of preventive medicine and hygiene60(3), E250. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797889/ (Links to an external site.)

Upon last week’s discussions surrounding the introduction of quality initiatives, I felt a strong desire to pay close attention to my work environment this week and identify some quality gaps in my workplace. I decided to strike up a conversation with my unit manager regarding our unit’s specific quality/safety initiative needs and together we discussed a multitude of areas that could use some improvement on our floor. One quality initiative that really stuck out was the need to improve on the number of readmissions we experience as a cardiac unit at a community hospital. We discussed a new pilot program the hospital has been implementing on other units that involves using LACE scores to identify patients at a high risk of readmission and targeting them for extra support. I am now planning on assisting with this pilot program to be implemented on my unit starting next month.

A quality gap is described as the difference between an expected level of care to be provided and the actual measured outcomes provided (Ogrinc et al., 2018). For this initiative, the quality gap would be that patients should not be readmitted to the hospital within 30 days of discharge, however this does unfortunately happen fairly often in my hospital. Not only are readmissions not reimbursed, they represent a poor quality of life for patients who should be living their lives outside of hospital walls. A potential benchmark of this quality initiative is to keep track of the 30 day readmission rate for patients on the unit. This is a frequently used benchmark, and most importantly the 30 day readmission benchmark is utilized by the Hospital Readmissions Reduction Program (HRRP) and Centers of Medicare and Medicaid (CMS) to determine hospital remibursement (McIlvennan et al., 2015). While a proper root cause analysis will provide the most accurate answers as to the cause of readmissions on my unit, at this point I can attribute this quality gap to lack of discharge teaching, lack of follow up appointments being made and medication/ lifestyle noncompliance from patients.

While researching my potential quality initiative topic, I read an article entitled, Reducing All-cause 30-day Hospital Readmissions for Patients Presenting with Acute Heart Failure Exacerbations: A Quality Improvement Initiative, and found that it mirrors my goal of utilizing nursing interventions such as patient education and scheduling follow up appointments to decrease readmission rates (Nair et al., 2020). This quality initiative first used retrospective data on patients who had been admitted to inpatient care with a CHF exacerbation diagnosis to determine readmission patterns, including what percentage of these patients had a scheduled follow up appointment with either cardiology or their primary care physician. These researchers then focused on a new cohort of patients in a CHF exacerbation and implemented several interventions such as ensuring their follow up appointments were made, focusing on appropriate patient education from the nursing staff, which also included increasing nursing staff for adequate support, and optimizing heart failure medications. These interventions decreased readmission by 50% (Nair et al., 2020)! This article has reinforced the idea that when at risk groups are targeted and extra support is offered, an improvement in patient outcomes can be made.

 

McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation, 131(20), 1796–1803. https://doi.org/10.1161/CIRCULATIONAHA.114.010270

Nair, R., Lak, H., Hasan, S., Gunasekaran, D., Babar, A., & Gopalakrishna, K. V. (2020). Reducing all-cause 30-day hospital readmissions for patients presenting with acute heart failure exacerbations: a quality improvement initiative. Cureus, 12(3), e7420. https://doi.org/10.7759/cureus.7420

Ogrinc, G. S., Headrick, L. A., Barton, A. L., Dolansky, M. A., Madigosky, W. S., Miltner, R. S. (2018). Fundamentals of health care improvement: A guide to improving your patients’ care (3rd ed., p.8). Joint Commission Resources and Institute for Healthcare Improvement.