Quality Improvement: Action Plan

Instructions

Quality measures are methods to appraise health care by using standards. The purpose of these measures are to make sure all patients get the right care at the appropriate time. Refer back to your Fishbone Diagram in the Quality Improvement: Preventable Errors assignment in Week 1 and select two areas of improvement you focused on and identify quality measures that will help decrease a preventable error.

ORDER  HERE A PLAGIARISM-FREE PAPER HERE

(Two chosen areas that are selected based on HCAPHS scores (the lowest HCAPHS scores): 1. Quietness at night around a patient’s room–ex. ↑ noise level—>disturb the patient’s healing time, etc & 2. Discharge instructions/education—ex. Did patients understand their care after they left the hospital?

Write a 1,050-word action plan for your Quality Improvement Action Plan identifying the steps you will take to implement the improvement.

Utilize the Quality Improvement Project Action Plan provided by the Office of Mental Health to guide you in completing your Quality Improvement Action Plan (Here is the website for Quality Improvement Action Plan forms:  https://www.omh.ny.gov/omhweb/psyckes_medicaid/initiatives/freestanding/project_tools/cqi/handbook/action_plan_blank.pdf). Your outline should be structured to address the issue that needs to be changed, the impact the issue has on the organization’s quality, and how you will improve quality. Also, need to create an action plan for each selected improvement.

Please address the areas below thoroughly including sub-bullets:

• Compare and contrast quality measures that are appropriate for what you’re looking to improve.
  • Which measure did you select for your quality improvement and why?
• What changes can you make that will lead to improvement? Include the PDSA Cycle (one PDSA cycle for each selected areas) in your response.
• Consider the organization’s mission and vision (I have attached an file to help with Glendale Memorial Hospital’s mission and vision).
  • Does the plan in your PDSA trials fit with the organization’s practice and model? For example, do they include thoughtful strategies that fit with the culture of your staff and patients?
• What are the internal and external influences to the organization for each problem? Use supporting details from the textbook to support your answer. (This is our text book:  Sadeghi, S., Barzi, A., Mikhail, O., & Shabot, M. (2013). Integrating Quality and Strategy in Health Care Organizations (1st ed.). Burlington, MA: Jones & Bartlett Learning).
• How do you know a change is an improvement?
• Summarize your action plan steps and address which area of improvement is more appropriate for you to adopt and which area of improvement you will discard based on the results of your PDSA plan. Explain why or why not.

Compare and contrast quality measures that are appropriate for what you’re looking to improve. Which measure did you select for your quality improvement and why?

A review of the HCAPHS score for Glendale Memorial Hospital and Health Center (GMHHC) reveals that the performed poorly in two areas. The first area is quietness at night around the patients’ rooms where the patients noted high noise levels that interfered with their night rest and healing progression. The second area is discharge education and instructions whereby the patients reported that they did not understand the home care needs and requirements even as they left the facility. Quality Improvement: Action Plan In this case, quality is defined as the capacity of the facility to offer medical services that increase the probability of achieving the desired care outcomes and are congruent with the current professional standards and knowledge. For that matter, there is a need to apply quality improvement.

ORDER  HERE A PLAGIARISM-FREE PAPER HERE

There are two quality measures that can be applied to the present situation. The first quality measure is standardization that entails systematization and alignment. Systematization ensures that all input achieve an anticipated outcome within the boundaries of certainty with little to no randomness. Alignment ensures that practice is matched with evidence (Meyer, 2016). Quality Improvement: Action Plan The second quality measure is PDSA (plan-do-study-act) that entails the use of a series of steps to identify the system, process and patient aspects linked with the problem. Through repeating the PDSA cycle, it is possible to achieve the desired outcome with the focus on process and structure. For the present case, PDSA is more appropriate since the two quality problems are concerned with process and structure. The process aspect includes human capital in terms of training and education, as well as knowledge capital in terms of standard operating procedures. The structure aspect includes the facility culture, leadership and physical assets (Cotton, 2016). In this respect, PDSA is the more appropriate quality measure since it facilitates good decision-making that improves the possibility of good results and reduces the likelihood of unforeseen adverse results Quality Improvement: Action Plan.

What changes can you make that will lead to improvement?

The quality improvement action plan identified two areas of focus. The first focus area seeks to eliminate the irritating night noise over the next six months to ensure that there is quietness at night to facilitate night rest and facilitate the healing process. The specific actions to be undertaken include revising the facility plan to ensure that wards and patient rooms are located away from noisy areas, applying noise suppression technologies, repairing and replacing noisy equipment with quieter equipment, and soliciting support from other facilities in close proximity to ensure that they suppress noise and do not interfere with the facility activities Quality Improvement: Action Plan.

The second focus area is seeking to improve discharge education and instructions so that patients are better prepared to understand their medical care needs even when at home. The specific actions to be undertaken include revising the discharge education and instruction approaches to ensure that they are more comprehensive, educating medical personnel on how best to apply discharge education and instruction for the desired care outcomes, including family members and home-care givers as part of the audience, and creating a telephone-based and internet-based information support system that complements discharge education by addressing the patients’ concerns while at home Quality Improvement: Action Plan.

Consider the organization’s mission and vision. Does the plan in your PDSA trials fit with the organization’s practice and model? For example, do they include thoughtful strategies that fit with the culture of your staff and patients?

GMHHC is a medical facility concerned with providing health care services. The facility’s mission is to extend the Christian notion of care to the previously ignored and suppressed communities with the intention of improving quality of life. The facility’s vision is to create a forum for healthcare stakeholders to integrate their efforts to achieve the national medical care goals (Dignity Health Glendale Memorial Hospital, 2017). The facility’s mission and vision align with the PDSA since they are concerned with ensuring that the best possible care is delivered to patients to guarantee good outcomes. To be more precise, the PDSA approach includes thoughtful strategies by adopting a multimodal approach whereby different possible causes of the problem are identified and optimized to achieve the desired outcome. In fact, the approach ensures that all concerned stakeholders are able to make meaningful contributions towards solving the existing problems Quality Improvement: Action Plan.

What are the internal and external influences to the organization for each problem?

The first problem is noise that interferes with the patients’ night rest. The internal influences for this problem are an unfavorable facility plan, badly designed rooms and wards, and noisy equipment. The external influences are the facilities in close proximity to the hospital. These influences were identified based on the fact that they either cause night noise or are not able to suppress night noise as would occur in an ideal situation.

The second problem is the patients being discharged with limited home care information that causes them to make mistakes that have a negative effect on their care outcomes. The internal influences for this problem are inadequate discharged education and instruction approaches, medical personnel with limited knowledge, and absence of an information support system that address the patients’ concerns. Quality Improvement: Action Plan The external influences are the patients, family members and home-care givers who have limited knowledge about care requirements.

How do you know a change is an improvement?

Changes to the internal and external influences is anticipated to address the two problems and achieve the desired outcome. Changes to the influences would address the first problem by eliminating the irritating night noise. A revised facility plan would keep patients away from noisy environments. Installing noise suppression and dampening material would exclude outside noise. Quiet equipment would reduce noise levels. Getting the neighboring facilities to reduce noise pollution would ensure that the environment is quieter at night.

Changes to the influences would address the second problem by improving discharge education and instructions so that patients are better prepared to understand their medical care needs even when at home. A comprehensive discharge education plan would better prepare patients to address their home care needs. Better informed discharge personnel would be able to meet the patients’ education needs. Better informed home care providers would reduce the pressure that patients feel while at home by aiding them in making good care decisions. An information resource center would allow patients to access required care information. In this respect, the planned changes are anticipated to produce improvements that achieve the desired outcomes Quality Improvement: Action Plan.

Summarize your action plan steps and address which area of improvement is more appropriate for you to adopt and which area of improvement you will discard based on the results of your PDSA plan. Explain why or why not.

The first improvement entails better management of night noise levels. Four actions are intended for this solution. The first step is to revise the facility plan and repurpose buildings to ensure that wards and patient rooms are located away from noisy areas. The intended outcome is to locate noisy equipment and rooms away from the inpatient wards with the measurement of success being a new facility plan that positions noisy rooms away from rooms intended to be quiet. The second step is to apply noise suppression technologies with the intended outcome being the reduction of noise levels in patient rooms and wards. Quality Improvement: Action Plan The measurement of success will be the installation of noise suppression and dampening material in patients’ wards and rooms. The third step is to repair and replace noisy equipment with quieter equipment with the intended outcome being that all equipment used in the facility remain quiet. The measurement of success will be having quiet equipment that do not produce irritating noise at night in the facility. The final step is to solicit support from other facilities in close proximity to ensure that they suppress noise and do not interfere with the facility activities with the intended outcome being reduced noise pollution in the surrounding. The measurement of success will be absence of noise pollution from neighboring facilities. The success of the four steps will be determined based on how patients evaluate the night noise levels.

The second improvement entails applying more comprehensive discharge education and instructions. The first step is to revise the discharge education and instruction approaches to ensure that they are more comprehensive with the intention being to present a more comprehensive discharge education plan that addresses the patients’ home care needs. Quality Improvement: Action Plan The measurement of success will be the presentation of a comprehensive discharge education plan that addresses the patients’ home care needs. The second step is to educate medical personnel on how best to apply discharge education and instruction for the best outcomes with the intention being to have better-informed personnel who are able to anticipate and meet the patients’ discharge education needs. The measurement of success is to have better-informed discharge personnel who can anticipate and meet the patients’ education needs. The third step is to include family members and home-care givers as part of the audience with the intended outcome being better-informed home care providers who can supplement the patients’ knowledge to improve care outcomes. The measurement of success would be better informed home care providers who reduce the pressure that patients feel while at home. Quality Improvement: Action Plan The final step entails creating a telephone-based and internet-based information support system that complements discharge education by addressing the patients’ concerns while at home with the intended outcome being to create an information resource center available from home to allow the patients consult in case of any concerns while at home. The measurement of success would be the presence of an information resource center that patients can access using telephone and internet devices while at home. The success of the four steps will be determined based on the percentage of patients requiring hospitalization within 3 months of discharge owing to care mistakes made at home.

References

Cotton, D. (2016). The smart solution book: 68 tools for brainstorming, problem solving and decision making. London: Pearson Education Limited.

Dignity Health Glendale Memorial Hospital (2017). Dignity Health Glendale Memorial Hospital: community health implementation strategy 2017-2019. Retrieved from https://www.dignityhealth.org/-/media/cm/media/documents/IS/2017-GlendaleMemorial-ImplementationStrategy.ashx?la=en&hash=12AA0E34CB3E5F7F54F248C26E21E9DD90ACCBAB

Meyer, K. (2016). The simple leader: personal and professional leadership at the nexus of lean and zen. Morro Bay, CA: Gemba Academy LLC Quality Improvement: Action Plan