Assessment 2 Instructions: Executive Summary • PRINT • Write an executive summary, 4-5 pages in length, of existing outcome measures related to a performance issue uncovered in your gap analysis that you intend to address. Introduction Note: Each assessment in this course builds on the work you completed in the previous assessment. Therefore, you must complete the assessments in this course in the order in which they are presented. As a nurse leader, you must be able to access, identify, and describe outcome measures as they relate to safety and quality problems in your organization. This assessment provides an opportunity to examine existing outcome measures, assess their strategic value, and present your findings to executive leaders in a manner that will help you gain their support. Quality and safety are everyone's responsibility as a team of interprofessional care delivery partners. Together we develop policies that support quality and safe care delivery. As part of the interprofessional team, nurses are leaders in care and thus are responsible and accountable for leading and providing safe quality care. Health care delivery is structured around evidenced-based information. Quality is defined by exploring proven, evidenced-based information. After reviewing and defining evidencedbased information, the interprofessional team applies this knowledge to assess the organization's or the practice setting's ability to provide evidenced-based care delivery. When a gap in care is identified, it is important to propose an evidenced-based change and to execute a plan for improved care. Your summary of relevant outcome measures is based on your findings from the quality and safety gap analysis you completed in the previous assessment. Preparation Your analysis of the gap between current and desired performance was the first step toward improving outcomes. You now have the information you need to move forward with proposed changes. Your next step is to focus on existing outcome measures and their relationship to the systemic problem you are addressing. For this assessment, you have been asked to draft a summary of existing outcome measures for your organization's executive team to raise awareness of the problem and the strategic value of existing measures. Note: Remember that you can submit all or a portion of your draft summary to Smarthinking for feedback before you submit the final version of this assessment. However, be mindful of the turnaround time of 24–48 hours for receiving feedback, if you plan on using this free service. As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment. Building stakeholder support is crucial to fostering and sustaining change. Therefore, as you approach this assessment, think about the stakeholders whose support you will need for the change you want to bring about. • • What information is most essential for both the formal and informal stakeholders to understand about the proposed change? How might you communicate the need for change using just a few sentences (this is often referred to as an "elevator speech"). The following resources are required to complete the assessment. • APA Style Paper Template [DOCX]. Use this template for your executive summary. Requirements Note: The requirements outlined below correspond to the grading criteria in the Executive Summary Scoring Guide. Be sure that your written analysis addresses each point, at a minimum. You may also want to read the Executive Summary Scoring Guide and Guiding Questions: Executive Summary [DOCX] to better understand how each criterion will be assessed. Composing the Executive Summary • • • • • Explain key quality and safety outcomes. Determine the strategic value to an organization of specific outcome measures. Analyze the relationships between a systemic problem in your organization or practice setting and specific quality and safety outcomes. Determine how specific outcome measures support strategic initiatives related to a quality and safety culture. Determine how the leadership team would support the implementation and adoption of proposed practice changes affecting specific outcomes. Writing and Supporting Evidence • • Write clearly and concisely, using correct grammar and mechanics. Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style. Additional Requirements Format your document using APA style. Use the APA Paper Template linked above. Be sure to include: • A title page and reference page. An abstract is not required. • A running head on all pages. • Appropriate section headings. • Properly-formatted citations and references. • Your summary should be 4–5 pages in length, not including the title page and reference page. Portfolio Prompt: You may choose to save your executive summary to your ePortfolio. • Competencies Measured By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: • • • Competency 1: Analyze quality and safety outcomes from an administrative and systems perspective. • Explain key quality and safety outcomes. • Analyze the relationships between a systemic problem in an organization and specific quality and safety outcomes. Competency 2: Determine how outcome measures promote quality and safety processes within an organization. • Determine how specific outcome measures support strategic initiatives related to a quality and safety culture. Competency 3: Determine how specific organizational functions, policies, processes, procedures, norms, and behaviors can be used to build reliability and high-performing organizations. • Determine the strategic value to an organization • • of specific outcome measures. Competency 4: Synthesize the various aspects of the nurse leader's role in developing, promoting, and sustaining a culture of quality and safety. • Determine how a leadership team would support the implementation and adoption of proposed practice changes affecting specific outcomes. Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards. • Write clearly and concisely, using correct grammar and mechanics. • Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style. Resources: Writing Executive Summaries • • PRINT The following resources will help you in writing your executive summary. • • • Greenhalgh, T., Vijayaraghavan, S., Wherton, J., Shaw, S., Byrne, E., Campbell-Richards, D., Bhattacharya, S., Hanson, P., Ramoutar, S., Gutteridge, C., Hodkinson, I., Collard, A., & Morris, J. (2016). Virtual online consultations: Advantages and limitations (VOCAL) study. BMJ Open, 6(1). doi:10.2196/humanfactors.937 1 Markowitz, E. (n.d.). How to write an executive summary. Inc. http://www.inc.com/guides/20 10/09/how-to-write-anexecutive-summary.html • This article provides tips on writing executive summaries and offers links to additional resources that show you examples of using executive summaries for benchmarks and branding. Vila Health: Quality and Safety Gap Analysis. • This interactive exercise introduces best practices for writing an executive summary, which may help you with the assessment. Resources: Executive Summary Examples • • PRINT The following documents provide examples of how various executive summaries are written. • • • Schmid, D. A., & Huber, F. (2019). Brand love: Emotionality and development of its elements across the relationship lifestyle. Psychology & Marketing, 36(4), 305-320. doi:10.1002/mar.21180 Kissam, S. M., Beil, H., Cousart, C., Greenwald, L. M., & Lloyd, J. T. (2019). States encouraging value-based payment: Lessons from CMS's state innovation models initiative. The Milbank Quarterly, 97(2), 506-542. https://doi.org/10.1111/14680009.12380 Miller, D., Pearsall, E., Johnston, D., Frecea, M., & McKenzie, M. (2017). Executive summary: Enhanced recovery after surgery: best practice guideline for care of patients with a fecal diversion. Journal of Wound, Ostomy and Continence Nursing, 44(1), 74-77. • This example shows guidelines for best practice. Resources: Strategic Planning • • PRINT The following resources will help you in addressing the strategic value of existing outcome measures. • • Health Research & Educational Trust. (2014). Hospital-based strategies for creating a culture of health [PDF]. http://www.hpoe. org/ReportsHPOE/hospital_based_strategie s_creating_culture_health_RWJF .pdf Ehteshami, A., SaghaeiannejadIsfahani, S., Samadbeik, M., & Falah, K. (2018). Formulating telemedicine strategies in Isfahan University of Medical Sciences. Acta Informatica Media, 26(3), 169-174. https://doi.org/10.5455/aim.2 018.26.169-174 1 Quality and Safety Gap Analysis Elke Guerrero Capella University NURS-FPX 6212: Health Care Quality and Safety Management Professor Mary Ellen Cockerham January 27th,2022 2 Quality and Safety Gap Analysis Healthcare organizations are identifying and utilizing measures to attain or sustain corporate performance through the consistent delivery of patient-centered and value-based care to their clients. While several organizations are executing their strategic plans successfully, others are struggling with the identification of improvement areas in their organization. Also, some hospitals and clinics lack the resources to implement the right quality improvement programs for accomplishing these goals (Kiyoshi-Teo, Carter, & Rose, 2017). Washington Hospital belongs to the category of those who need to not just identify the gaps in the quality and safety practices but source the financial resources to execute corrective measures. As a result, this analysis paper would describe the dangers of patient falls to outcomes and performance, propose critical practice changes, and analyze and justify the practice changes that foster safety and quality and how organizational culture impacts them. Therefore, the objective is to determine the gaps and recommend the practice measures to close them to deliver quality and safe care to patients. Description of the Systemic Problem Washington Hospital is a secondary critical and emergency care facility with a 200-bed capacity to admit both pre-operative and post-operative patients. As the leading and reputable accident and trauma care in the county, the hospital is preferred by providers for referring patients who need specialist consultations and care. The management and staff of this facility are committed to delivering safe care and supporting patients to achieve the treatment goals. However, the recent report by the hospital's quality improvement committee showed that there is a consistent increase in the rate of its fall in the past six months. According to Frieson, Tan, Ory, and Smith (2018), the falls rate is calculated as the number of falls per 1,000 patients due to 3 unintentional descent to the floor that results in injury or otherwise. The report noted that while the national falls rate ranges from 3 to 12, the rate at Washington has remained at 10.5 for the past four months in the post-operative care and telemetry units. Hence, this is a major safety problem for the organization. Meanwhile, a comparison of the hospital's fall rate with the national average shows that it is not just high, but the 50% of these falls that result in patient injury and the associated cost of treatment (Moreland, Kakara, & Henry, 2020). Aside from the internal concerns regarding the number of severe injuries from the falls and the burden of cost on the patients, the potential impact on organizational finances due to the non-reimbursement of a preventable near miss or adverse events by Medicare and Medicaid is the greatest issue for Washington Hospital. Also, the likelihood that this high falls rate would affect the hospital's accreditation and recognition as a Magnet Hospital demonstrates how this problem is a performance issue that should be addressed through evidence-based practice changes. Therefore, patient falls are a major performance indicator for hospitals that should be maintained at lower levels to prevent its adverse impacts on their finances, accreditation, and reputation as the safe facility to receive care. Proposed Practice Changes The review of the quality improvement committee's report provided insights to practice areas in the hospital that needs to change to reduce the falls rate among its patients. First, the incident reports that were filed by the critical care nurses showed that falls occurred when patients attempt to leave their beds to use the bathrooms. Second, the nurses' documentation of the patient's medications did not include disorientation and a high potential for falls as part of the short-term effects. In this regard, most of these patients cannot support themselves when 4 attempting to utilize the bathrooms during hospitalizations. Third, the failure to categorize some of the hospitalized patients as at-risk for falls means that the hospital's prevention protocols for falls were initiated or adhered to by the bedside or acute nurse. As a result of the inaccurate documentation and categorization of high-risk patients, there is an urgent need to change these practices to achieve the falls rate reduction goals. Falls prevention protocols require an integrated approach to make them effective in contributing to organizational goals. Bargmann and Brundrett (2020) state that hospital systems for falls prevention should be designed to address the environmental, physical, and psychological factors that create the patient safety issues and based on the multidisciplinary approach. In this regard, it is proposed that practice changes for Washington Hospital should cover staff education on falls risk evaluation and classification, falls prevention protocol compliance monitoring, periodic assessment of high-risk patients, and incident reporting and handling procedure. While these practice changes are part of the ongoing quality improvement systems in the hospital, there are supported by evidence from Joint Commission's Tailoring Interventions for Patient Safety (TIPS) for patient fall prevention toolkit. Therefore, it is imperative to identify and prioritize the critical areas of the hospital's operations that require immediate practice changes to align them with the strategic plan. Proposed Priority Changes The education of bedside and critical nurses on the multidisciplinary protocols for falls prevention that are documented in the TIPS toolkit is one of the priority practice changes that Washington Hospital needs urgently. Studies show that the active engagement of key stakeholders, including nurses and physicians in the implementation of TIPS is a critical success factor in reducing falls rate and eliminating employee and leadership barriers (Dykes et al., 5 2020). Also, training and education are essential for updating the guidelines and certifying the critical care staff on these protocols for falls rate prevention. The other priority practice change is increased compliance monitoring by the hospital's patient safety group to identify issues in the systems and processes that increase the risk of falls in patients. Similarly, the active involvement of the group in evaluating compliance levels at all units would generate data on patient outcomes and new risk factors that can be used to improve the multidisciplinary protocol. As a team that consists of the Clinical Nursing Officer, Nurse Informaticist, Heads of Departments, and Nurse Managers, the patient safety group can use the information to identify the need resources such as bed and chair notification systems that are needed to achieve the falls rate reduction targets in all units. In summary, it is proposed that the priority practice changes should focus on staff education and increased compliance monitoring to achieve the reduction targets. Fostering Safety and Quality Culture The proposed practice changes are designed to foster the culture of safety and quality at Washington Hospital due to its role in improving staff skills and competence and demonstrating the importance of the new practice to sustainable growth. Also, nurses and other healthcare practitioners are patient advocates who have the ethical responsibility to prevent their clients from suffering injury or harm while receiving care (Heng et al., 2020). It implies that practice changes that enhance their professional duties and capacity to fulfill these responsibilities to patients would be supported by them. For example, the training sessions on the new protocols for falls prevention would discuss the link between the new guidelines and code of conduct of the American Nurses Association (ANA) to justify their significance to their nursing career. As result, the attitudes and behaviors of all relevant clinical and non-clinical staff towards the elimination of the environmental, psychological, and physical factors that contribute to the high 6 falls rate in the hospital would improve. Finally, it is vital to consider the influence of the organizational structure and reporting lines on the success of the changes because historical records showed that this aspect of the culture could delay the delivery of expected outcomes for all stakeholders. Impact of Organizational Culture on Outcomes Furthermore, the defining characteristics of Washington Hospital's culture that might quality and safety outcomes are the leadership support for quality improvement initiatives and staff's perception of the strategic plan on their workload. These elements of the culture determine the availability of resources for task execution, compliance rates, and utilization of the resources. In this regard, it is projected that these aspects of the culture and hierarchy at the hospital would result in positive outcomes due to the integration of measures to deal with them in the strategic plan. Also, the inclusion of the senior management in the patient safety group means that challenges with resource availability for training and compliance would be resolved promptly and employee support for the practice changes would increase accordingly. Hence, the defining characteristics of this hospital's culture will drive the efforts to achieve positive outcomes from after the implementation of the practice changes. Rationales for Proposed Changes In conclusion, the justification for the proposed practice changes at Washington Hospital exists in their positive impacts on organizational performance, patient satisfaction, staff retention, and sustainable growth goals. First, the effects of changes in the attitude and behaviors of clinical and non-clinical towards the environmental and administrative causes of the high falls rate justify their education and involvement in the procedures (Dykes et al., 2020). Second, the involvement of senior management in the compliance monitoring processes means that 7 communication and resolution of issues are done promptly. Third, there is evidence from studies that the sense of ownership that the staff develops after the training would result in new paradigms that contribute to safe and quality care in all units. Finally, the proposed practice changes do not increase the workload of the nurses, which is required to make the nurses avoid workarounds during an increase in high patient demands. 8 References Bargmann, A. L., & Brundrett, S. M. (2020). Implementation of a multicomponent fall prevention program: Contracting with patients for fall safety. Military medicine, 185(Supplement_2), 28-34. https://doi.org/10.1093/milmed/usz411 Dykes, P. C., Burns, Z., Adelman, J., Benneyan, J., Bogaisky, M., Carter, E., ... & Bates, D. W. (2020). Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: a nonrandomized controlled trial. JAMA network open, 3(11), e2025889e2025889. doi: 10.1001/jamanetworkopen.2020.25889 Frieson, C. W., Tan, M. P., Ory, M. G., & Smith, M. L. (2018). Evidence-based practices to reduce falls and fall-related injuries among older adults. Frontiers in public health, 6, 222. https://doi.org/10.3389/fpubh.2018.00222 Heng, H., Jazayeri, D., Shaw, L., Kiegaldie, D., Hill, A. M., & Morris, M. E. (2020). Hospital falls prevention with patient education: a scoping review. BMC Geriatrics, 20(1), 1-12. Kiyoshi-Teo, H., Carter, N., & Rose, A. (2017). Fall prevention practice gap analysis: Aiming for targeted improvements. MedSurg Nursing, 26(5), 332-335. Retrieved from https://www.researchgate.net/publication/325999697_Fall_prevention_practice_gap_anal ysis_Aiming_for_targeting_improvements Moreland, B., Kakara, R., & Henry, A. (2020). Trends in nonfatal falls and fall-related injuries among adults aged≥ 65 years—United States, 2012–2018. Morbidity and Mortality Weekly Report, 69(27), 875. doi: 10.15585/mmwr.mm6927a5
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