Quality Plan

Posted: January 4th, 2023

9-1 Final Project Submission: Quality Plan

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9-1 Final Project Submission: Quality Plan

The following performance improvement plan intends to reduce the number of patient falls in the critical care unit of a community hospital. The hospital is located in South Korea, a country renowned for its rapid technological development and universal health converge. However, despite the wide adoption of technology in the healthcare organizations in the country, comprehensive meaningful-use is yet to be achieved even at the hospital. Incidences of patients’ falls are on the rise as an increasing number of elderly patients are admitted into critical care. This quality improvement plan intends to resolve this healthcare challenge using innovative application of a patient surveillance system.

Purpose and Quality Statement

Quality plans in healthcare organizations are demonstrations of the keen interest and commitment to improve continuously the delivery of high-quality healthcare services to patients and the community. They have become a critical component and product of strategic planning in the healthcare sector, in response to the high demand for patient-centered care, accountability and improved patient outcomes. Patient safety is one of the most critical areas addressed by quality plans because it not only influences the satisfaction and uneventful recovery of patients but also places the healthcare organization in good light, professionally and socially, giving it the social license to operate. It is therefore, a critical element in improved care quality and health outcomes. Patient safety is essentially the absence of harm to a patient while accessing healthcare services (World Health Organization, 2019). It is anchored by the continuous improvement of care quality resulting from the lessons learned from adverse effects and errors in the healthcare setting with the intention of reducing, efforts, risks and harm to the patient. The world health organization (2019) emphasizes that the quality of healthcare is gauged by the safety of patients along with the effectiveness and patient-centeredness of care. In turn, repeated observance of patient safety promotes a safety culture in a healthcare organization, which is a mark of high quality standards therein.

Healthcare organizations are incentivized to establish high standards of patient care through accreditation. According to Richie, et al. (2019) accreditation is a system used to assess the commitment of healthcare organizations towards continuous improvements in quality of services and care using recognized third-party assessments. The accreditation process followed a well-laid out and strict procedure that is well known and often, based on universally acceptable standards. The Joint Commission (TJC), is the most influential and significant accrediting body across many states in the United States, and employs an extensive metric comprising 25 performance measures that a healthcare organization must satisfy before being accredited (Nash et al., 2019). Accreditation promotes patient safety by emphasizing particular safety competencies and capabilities and increasing vigilance in healthcare organizations, as evidenced by Lyle-Edrosolo and Waxman (2016) and Barnett et al. (2017), respectively. 

The healthcare organization under consideration is particularly concerned about the occurrences of falls among patients. This concern is a reflection of the organizations vision and mission, which articulate the commitment to providing high-quality healthcare to all patients and improving the health wellbeing of families and the community (Health Resources and Services Administration, 2011). Persistent falls are an indication of low patient safety levels and poor quality services in a healthcare organization, which can undermine the realization of the organization’s goals. The mission statement of the hospital is to ‘serve with diligence and compassion’, and policies directing the operational processes and procedures are well articulated and documented. These statements were used to formulate the philosophy underpinning the quality plan at the healthcare organization. Besides, they are congruent to the National Patient Safety Goals set for hospitals by The Joint Commission (2020), specifically, prevention of mistakes in surgery and infection, identification of patient safety risks, safe use of medicines and alarms, improvement of staff communication, and correct identification of patients.

The performance-improvement process anticipated by the quality plan requires a multidisciplinary, multiprofessional, and multidepartmental approach. Therefore, the plan will require the involvement of and collaboration between different critical stakeholders, who are identified as nursing practitioners, patients, nursing leadership, physicians, hospital administrators, and the families of patients. The inherent nature of patient care, which required the employment of diverse and effective teams, informed the engagement of this stakeholder group (Hicks & Nininger, 2012). Each of these parties is concerned about and has a stake in the welfare of patients and advocate for a safe and caring environment, particularly in a healthcare setting. They are related as illustrated in figure 1.

Figure 1. Organizational Chart of the stakeholders

Although the community hospital in this quality plan has made significant progress in enhancing the quality of healthcare, more needs to be done, particularly in the acute care unit, where the level of patient falls is still worrisome. The older patients are at higher risk of falling while in hospital compared to younger ones, and the prevalence rate has been worsened by the aging population phenomenon, which as seen the proportion of the elderly in care increase gradually, as the huge number of baby boomer move past the middle age (Slade et al., 2017). For this reason, the quality statement that articulates the essence of the quality improvement plan is reduction of patient falls through the leadership of a safety committee. The clinical nurse leader at the community hospital’s intensive care unit will spearhead this initiative, which is expected to enhance the development, supervision, and testing of the specific measures according to the existing best practices in the healthcare industry.

Status of Quality Tools and Standards

The community hospital is accredited to the Korea Institute of Healthcare Accreditation since 2010 also to the Korean Institute of Healthcare Accreditation (KOIHA) since 2017 to comply with the Support for the Oversees Expansion of the Healthcare System and the Attraction of International Patients Act.  This has spurred the continuous improvement in the healthcare organizations in the country as they face the challenges of an ageing population (Lee, 2018; Shin, 2017). The hospital has benefited tremendously from the technological leadership and innovation of the country, and has automated all its healthcare processes using a health information management system that focuses electronic health and medical records (EHR/EMR), which had been adopted by 93.6% and 91.6% of Korean hospitals and clinics countrywide, respectively (Tursunov, Lenox, & Cleave, 2019). In this regards, the hospital joins many others in the country that have adopted electronic medical records (EMR) and gone paperless, making South Korea one of the few countries with near-universal digitization of healthcare services.

The health information technology (HIT) used at the hospital addresses two domains of the accreditation standards prescribed in the accreditation program for healthcare organizations by KOIHA; the patient care system and the administrative management system. Specifically, it facilitated the management of patient information and medication, organizational operations and management, simplified the scoring of clinical quality indicators, promoted the real-time sharing of pertinent patient information, which contributed to favorable scores during the accreditation evaluation process. Some of the accreditation criteria by KOIHA required that healthcare organizations demonstrate the use of technology and information management systems in the enhancement of the management and administration of patients’ information and medication, control of the occurrence and spread of infections, guaranteeing safety during sedation and surgery, and facilitating the evaluation of care delivery quality, among others. In these standards, elements of meaningful use of health information technologies are evident, as prescribed in the American law, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, although South Korea as yet to enact a similar directive to promote technology adoption and guide the accreditation of healthcare organizations (Furukawa, 2017; Tursunov, Lenox, & Cleave, 2019).

Nonetheless, the hospital’s meaningful-use application of the health information technology had helped reduce medication errors that undermined patients’ safety, while enhancing the levels of positive patient outcomes. However, despite these positive indicators, the hospital was still in the first stage of the three-stage process of attaining interoperability. Specifically, the hospital was using health information technology to capture patient data and share it within the organizational premises because the country still had restrictions on sharing health information inter-organizationally and especially, with third party providers (Tursunov, Lenox, & Cleave, 2019). This means that the hospital was yet to leverage digital technologies to advance clinical processes and improve health outcomes of patients, which were the second and third stages of entrenching meaningful use (Jones, et al., 2014). This may explain why the hospital and healthcare system in the country was especially challenged by the rising number of elderly patients and their complicated conditions, and the associated rapidly-rising healthcare costs, which were 4 percentage points above the OECD average of 2.1 % (Tursunov, Lenox, & Cleave, 2019). In other words, meaningful use of health information technology was yet to exert its full effect on the enhancement of quality of care and safety of patients at the hospital.

Measures and Benchmarks

The performance-improvement data at the hospital is tracked in a granulated manner at the departmental level, which are then aggregated to provide parameters that reveal the change in operational and clinical efficiency at the hospital level. Specifically, at the department level, specific events, such as number of admissions, transfers, and discharges per day, drug-to-drug contradictions per patient, and the exhibition of adverse drug reactions by elderly patients, are recorded on a daily basis. These metrics are used to compute the efficiency of operational and clinical activities as a percentage increase or reduction to provide a trend that reflects the improvement or degradation of health services at the organizational/hospital level. The resultant trends are tracked in real-time are they are computed immediately data in fed into the hospital’s health information system.

The reimbursement criteria will include the performance metrics from the program. However, unlike the United States, South Korea’s healthcare system uses a universal reimbursement approach based on the capitation model because of the universal health coverage (Kang, Kim, & Jung, 2020). This approach does not have a direct impact on patient safety and health service quality enhancement because it encourages the expansion of the patient base for monetary gains rather than service improvement (Nash et al., 2019). Nonetheless, this approach promotes access to healthcare, although this metric is not used for accreditation purposes. Despite these limitations in the nascent and developing healthcare system, leadership at the community hospital is increasingly collaborating with tech firms to research, develop and implement innovative technologies that would help reduce the cost and increase the quality of healthcare.

Process improvements

The elderly patients present many challenges to the hospital because their numbers are increasing in tandem with the aging population in the country. These patients present more co-morbidities compared to their younger counterparts, and therefore, are often under several prescriptions simultaneously, which increases the risk of adverse-drug-drug and drug-patient- interactions. Sometimes, medications disorient these patients such that, they engage in risky behavior, like leaving their beds without alerting the nurses, not using their crutches, walkers, or wheelchairs, and moving around aimlessly, thus exposing them to the risk of falling, despite being provided with alerting switches at their bedsides. The hospital does not have an uninterruptable system of visually observing patients to identify their conditions and progress, apart from the regular instruments found in an intensive care unit that are hooked directly to the patient. Therefore, the accuracy of patient identification is hindered by the lack of sufficient visual evidence of the behavior of elderly patients, particularly when they are under medication yet able to move around (Elgarico, 2019). From this premise, the goals of the quality improvement plan are a) to reduce the events of patients moving unattended, b) encouraging the use of bedside alert switches to call for assistance, c) to discourage the avoidance of movement-assisting devices, and d) reducing the events of falls by patients.

Therefore, it is recommended that a falls prevention safety committee that would help monitor and track the behavior of patients and nurses be formed to reduce the fall events at the acute care unit in the hospital. To this end, it is also recommended that nurses should record the events in which the patient attempts or actually moves out of bed with any assistance or calling for attention, the occurrence of drug-to-drug and drug-patient counter-indications that would indicate adverse reactions to medication by the patients.

A new technology that would facilitate the implementation of the quality improvement plan is closed-circuit televisions (CCTV), which would help monitor the behavior and movement of patients in the critical care units and intervene when the patients display behaviors that increase their risk of falling. These cameras should be fitted with motion sensors that detect abnormal movement of patients and alarms that become triggered by such movement or falls. This would not only help the nurses to anticipate the movement of the elderly patients, especially, who are at a high risk of falling, and therefore, take preventative measures, it would also help evidence the nature of falls too facilitate speedy and appropriate intervention, while discouraging patients from moving out of their beds unattended.

The proposed quality improvement program involves several stakeholders from diverse professions, locations, and disciplines, and with diverse interests. Therefore, a transformative leadership style is recommended as the most appropriate leadership strategy that can spur a change in attitude in the patients and healthcare workers. Specifically, this leadership approach incorporates coaching and mentoring of novice healthcare professionals, especially nurses, collaborative leaderships that seeks collective decision-making by involving all the stakeholders, and authentic leadership that accommodates the diverse and disparate opinions of stakeholders without making being judgmental. It is also inspirational because it encourages best performance from the healthcare workers, and hence, critical in guaranteeing the success of the quality improvement plan and enhancing patient safety at the acute care unit and hospital (McSherry & Pearce, 2016).  

A recommended policy change would be the recording of patients’ movement behavior and part of the patients’ personal health records. The use of CCTV footages as a diagnostic and monitoring tool for in-patients is critical for indentifying the responses of patients to medication, which would adversely endanger their safety (Morris, 2017). To implement these operational and policy recommendations, the involvement of the hospital’s administration is critical because they would avail the budget for procuring and implementing the electronic patient surveillance system. Similarly, the departmental heads of other healthcare units are critical to the effectiveness of the policy change because they would help diminish or prevent the possibility of resistance from nurses, clinicians, and other healthcare workers, who my view the system as being used to monitor their operations and activities at the workplace, thus infringing on their privacy (Kampstra et al., 2018). In these regards, these leaders would facilitate the buy-in from all the healthcare practitioners in their department and encourage the sharing of critical information that may jeopardize patients’ safety and diminish the quality of care at the hospital (McSherry & Pearce, 2016).

Evaluation and Reporting

The ultimate goal of the quality improvement program is to cut down the incidences of patients’ falls by 15% in 6 months. This is an ambitious achievement levels that will require prudent monitoring and evaluation processes that would deliver accurate reporting on the key performance indicators. It is proposed that the success of the program plan is hinged on the application of the Plan-Do-Study-Act (PDSA) implementation strategy to be undertaken within projected six months (Benson & Townes, 2011). In the planning stage, an interdepartmental and interdisciplinary falls prevention safety committee will be set up, to be headed by the clinical nurse leader in the intensive care unit at the hospital. This committee will devise a plan for selecting the technological requirements of the surveillance system, its third-party supplier, and identifying the training needs of the system users, especially, the nurses in the critical care unit. The plan will also outline the measurable components of performance, the activities of the implementers, and the data to be collected. The doing phase will perfect the stalled efforts of ensuring that patients did not move unattended and sufficient signage encouraging patients to seek help whenever they felt the need to move out of their beds, which would be augmented by the visual surveillance of their unattended movement. The data to be collected will include the number of incidences of unattended movement of patients, the number of assisted movement of patients, and the number of falls, slips, and uncoordinated movements in a day by patients. Other anomalous observations will also be recorded on a daily basis. The study stage will involve the analysis of the collected data, its comparison with the projected predictions, and a collation and reflection of the lessons learned. In the act phase, the program will be adjusted and modified using the feedback of the data analysis and lessons learned, to inform the next round of testing (Benson & Townes, 2011). Each PDSA cycle will last a month until the projected results are attained, which is summarized in figure 2.

Figure 2. The PDSA cycle of the quality improvement program plan

The successful implementation of the patient surveillance technology will be measured using parameters, such as i) the number of patient unattended movement identified through CCTVs, ii) the frequency of response by nurses from the alerts sent by the system, iii) the number of falls that went undetected, the number of possible falls that were prevented, iv) the frequency of use of the footages by nurses, and v) the information recorded in the patient’s health record from the surveillance system. This information will be condensed into specific performance metrics, such as the change in fall incidences and the frequency of data sharing. These metrics will move the meaningful use of health information technology from the data capturing and sharing stage, to the advancement of clinical processes and improvement of health outcomes. They will evidence the occurrence of drug-induced disorientation of the patients, thus improving medicine administration and safety, and elucidate improvements in health outcomes, by reducing the number of fall incidences at the acute care unit at the hospital, which are pertinent performance parameters for KOIHA accreditation. 

Conclusion

The proposed quality improvement program plan intends to reduce the number of patient falls by 15% within six months. A patient surveillance system using closed-circuit televisions will be implemented using the plan-do-study-act model to deliver a comprehensive practice change among the healthcare professionals attached to the critical care unit of a community hospital in South Korea.

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