1. Identify any existing quality concern or an existing patient safety issue and provide the rationale for choosing this issue.
2. Explain the background and scope of the problem.
3. Analyze the issue based on the appropriate quality philosophy.
4. Identify the regulatory guidelines, internal and/or external benchmarks, or evidence-based practice standards surrounding the issue—explain what that expectation is and why.
5. Use the appropriate quality improvement tools to improve the quality outcome.
6. Describe how you could or will get involved in this initiative to make a difference and move it forward to enactment.
7. Summarize the content in concluding statements.
PURPOSE:
The purpose of this assignment is to (a) provide examples of a quality improvement initiative or patient safety issue in any healthcare delivery setting, (b) explore the contributing factors for this adverse medical outcome, (c) apply quality improvement theories and philosophies to a healthcare management project, (d) demonstrate an understanding of quality improvement tools by correctly choosing and using them in specific cases, and (e) recognize the extent of problems of patient safety in medical care.  Quality Improvement Model Application Essay Paper

Quality Improvement Model Application

Quality improvement in healthcare refers to the deliberate actions taken to safeguard patient safety and comfort in the way that interventions are delivered. The concept of quality in healthcare is concerned with reducing the likelihood of human errors and adverse patient outcomes that may lead to the patient getting harmed or disabled (Spath, 2018). It was the Institute of Medicine (IOM) report of 1999 entitled To Err Is Human that first brought to the fore the role played by human error is destroying care quality in healthcare settings. The finding was that between 44,000 and 98,000 patients were dying preventable deaths annually in US hospitals due to errors committed by nurses and physicians (Palatnik, 2016). Quality improvement is facilitated by evidence-based practice. This is the application of only those interventions that can be explained in terms of efficacy and effectiveness by current published scientific and scholarly peer-reviewed literature (Melnyk & Fineout-Overholt, 2019). Quality healthcare is safe, timely, effective, efficient, equitable, and patient-centered (AHRQ, 2018). These are the six domains of healthcare as advanced by the IOM. The purpose of this paper is to present an existing patient safety issue and discuss the regulatory factors surrounding it.

An Existing Patient Safety Issue and Rationale for Choice

The existing patient safety issue that has been chosen for this paper is that of wrong-site and wrong-patient surgeries at a busy trauma center in a tertiary health institution. The issue involves the nurses taking to the operating room either the wrong patient to be operated on, or presenting the right patient but exposing the wrong site to be operated on (AHRQ, 2019). The rationale for the choice of this issue is that this kind of human error is a never event or sentinel event that should never happen in the first place. Its implications are dire for both the organization and the person or persons responsible for the error. Many a times the patient dies or gets a preventable permanent disability.

Sanctions can be imposed on the institution by the quality regulatory bodies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance or NCQA, and the Agency for Healthcare Research and Quality (AHRQ). But the direst of all would be the revocation of the practicing licenses of the persons involved and litigation for damages by the patient due to malpractice (Al-Haijaa et al., 2018). It is therefore clear from the above that this is indeed a very serious patient safety issue that requires to be addressed with the urgency that it deserves.

Background and Scope of the Problem

The tertiary 600-bed institution in which the trauma center is located has a good reputation for patient safety and the implementation of change initiatives for the advancement of evidence-based practice or EBP. That is why when the electronic health record (EHR) dashboard performance indicators started showing an increase in the rate of wrong-patient and wrong-site surgeries within the past three months, the Quality Improvement Committee (QIC) took notice.

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There had recently been an exodus of experienced trauma nurses working in the trauma units attached to the operating rooms and this necessitated a hurried recruitment and orientation process to fill the gap that was left. Soon, however; events that were hitherto unheard of at the trauma center started to occur with worrying frequency. Surgeons started operating on the wrong patients as well as on the wrong sites. The scope of the problem has become big because at present, four patients have sued the hospital for damages due to professional negligence that caused them harm. Three of them were wrong patients operated on while the fourth was a patient who had his left knee operated on when it was his right knee that had a torn meniscus. Quality Improvement Model Application Essay Paper

The matter has reached the hospital Board of Directors and the Director of Nursing Services has already resigned because of the matter. The nurses and the surgeons involved have all been summoned by their respective professional licensing bodies for explanations. However, the hospital has not sacked any of them resolving to adopt a just culture approach to solving the matter as it appears to be a systemic issue (Linda & Nancy, 2019). This is an appreciation of the fact that sentinel events such as these occur due to a succession of events not instigated by a single person.

The Issue and the Existing Quality Philosophy

As sated already, wrong-site surgeries (WSS) and wrong-patient surgeries (WPS) are never events or sentinel events that are not supposed to happen. The reason is that these events are entirely preventable if measures are taken appropriately. One of these measures is the respect for “time-out” procedures in the operating room (Pellegrini, 2017). That is the current quality philosophy with regard to this problem. It however appears in this case that this has not been taking place consistently as it should. Part of the reason has been advanced that the new recruits are relatively inexperienced and also did not receive enough orientation before starting to perform sensitive duties.  Quality Improvement Model Application Essay Paper

Generally speaking, these events are not the result of a single person’s mistakes. For instance, before the surgery, the surgeon is expected to visit the patient in the unit and mark the site of surgery with an indelible marker. This ensures that he will spot the error if it were to happen. The nurse can therefore present the wrong patient yes; but the surgeon should notice this. Also, other team members should notice that something is amiss during one of the time-out moments. But if the “time-out” procedures are not respected, no one will notice and that is how these sentinel events end up occurring. It is extremely unacceptable and should never be allowed to happen at all.

Regulatory Guidelines, Benchmarks, and EBP Standards

The regulatory guidelines are majorly by the JCAHO and state that “time-out” procedures must be adhered to consistently and regularly without exception. Internally, the organization has a zero tolerance policy to human errors and spends a lot on continuous training to see that this is possible. It has also invested heavily in technology for the same purpose. For this problem, it is looking forward to investing in an electronically-mediated time-out platform that will force the staff to respect “time-outs” (Rothman et al., 2016).

Externally as it is internally, the benchmark is that there should never be a sentinel event such as this. The EBP standards are even clearer: the surgeon should visit the patient the day before and mark the site; the nurse should have a colleague confirm that it is the correct patient and that the site is correct before taking the patient for operation; and at the operating room the receiving nurse should also countercheck all details before receiving the patient.

Appropriate Quality Improvement (QI) Tool to Improve the Outcome

FADE is the QI model or procedure that has been chosen in this scenario (Spath, 2018). The acronym stands for Focus, Analyze, Develop, and Evaluate. This model is chosen since it is straightforward to implement and does not have any underlying conceptual complexities. The focus of the QI team will be on the problem which they will then analyze and develop solutions. These will be implemented after which an evaluation exercise will take place to find out if the problem has been resolved.

Nurse Involvement in the Initiative

The nurse is the most prominent patient advocate. For this reason, I will fully get involved in the initiative by disseminating the EBP recommendations to colleagues including those related to “time-outs”. I will also get as much current information as possible on the best practices to preventing wrong-site and wrong-patient surgeries as sentinel events.

Conclusion

The quality issue of concern selected for this paper is WSS and WPS which are both never events or sentinel events. Their consequences are great and include litigation for damages as well as revocation of practicing licenses. The problem can however be solved through a QI approach by using the FADE tool. This will enable the taking of corrective measures and a return to delivery of care that is safe, timely, effective, efficient, equitable, and patient-centered.

References

Agency for Healthcare Research and Quality [AHRQ] (2018). Six domains of health care quality. https://www.ahrq.gov/talkingquality/measures/six-domains.html

Agency for Healthcare Research and Quality [AHRQ] (2019). Wrong-site, wrong-procedure, and wrong-patient surgery. Patient Safety Network. https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

Al-Haijaa, E.A., Ayaad, O., Al-Refaay, M., & Al-Refaay, T. (2018). Malpractice: An updated concept analysis and nursing implication in developing countries. Journal of Nursing and Health Science (IOSR-JNHS), 7(1), 81-85. https://doi.org/10.9790/1959-0701078185

Linda, P., & Nancy, S. (2019). Just culture: It’s more than policy. Nursing Management (Springhouse), 50(6), 38-45. https://doi.org/10.1097/01.NUMA.0000558482.07815.ae

Melnyk, B.M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice, 4^th ed. Wolters Kluwer.

Palatnik, A. (2016). To err is human. Nursing Critical Care, 11(5), 4. https://doi.org/10.1097/01.CCN.0000490961.44977.8d

Pellegrini, C.A. (June 1, 2017). Time-outs and their role in improving safety and quality in surgery. Bulletin of the American College of Surgeons. https://bulletin.facs.org/2017/06/time-outs-and-their-role-in-improving-safety-and-quality-in-surgery/

Rothman, B.S., Shotwell, M.S., Beebe, R., Wanderer, M.Phil., J.P., Ehrenfeld, J.M., Patel, N., Sandberg, W.S. (2016). Electronically mediated time-out initiative to reduce the incidence of wrong surgery: An interventional observational study. Anesthesiology, 125(3), 484-494. https://doi.org/10.1097/ALN.0000000000001194

Spath, P.L. (2018). Introduction to healthcare quality management, 3^rd ed. Health Administration Press.  Quality Improvement Model Application Essay Paper