Archives: Portfolio

A recent trend identified by The Joint Commission (TJC) concerns hospital discharge procedures for heart failure (HF) patients. This information is considered publicly reported data, meaning that the compliance of the facility is available to the public. Seven elements are required for each discharge—diet, fluid restriction, activity level, when to call a physician, time for the follow-up appointment, clear medication directions, and specific signs and symptoms of HF problems (peripheral edema, shortness of breath, activity intolerance). The quality assurance team is charged with achieving 100% compliance with indicators for each aspect of the discharge process. 

1. According to the Nursing Today textbook, what are quality indicators and how do indicators differ from a metric?

2. What is the quality indicator in this scenario?

3. What is the rationale for having publicly reported data?

4. To achieve compliance, which procedures would need to be implemented regarding staff nurses?

Solution

1. Quality Indicators vs. Metrics:
   • Quality indicators are specific measures used to assess the quality of care provided by healthcare organizations. They are evidence-based standards or guidelines against which performance is evaluated.
   • Indicators reflect the outcomes or processes of care that are important for achieving desired patient outcomes or meeting organizational goals. They provide information about the quality, safety, and effectiveness of healthcare services.
   • Metrics, on the other hand, are quantitative measurements used to track and monitor performance over time. While quality indicators focus on specific aspects of care delivery, metrics provide numerical data to assess performance, identify trends, and measure improvement.
2. Quality Indicator in this Scenario:
   • The quality indicator in this scenario is the compliance rate with the seven elements required for hospital discharge procedures for heart failure (HF) patients. These elements include aspects such as diet, fluid restriction, activity level, medication instructions, follow-up appointments, and recognition of signs and symptoms of HF problems.
3. Rationale for Publicly Reported Data:
   • Publicly reported data serve several purposes:
     • Accountability: Transparent reporting holds healthcare organizations accountable for the quality and safety of care they provide, fostering trust and confidence among patients, families, and the public.
     • Consumer Empowerment: Access to performance data enables patients and their families to make informed decisions about healthcare providers and services, empowering them to seek high-quality care.
     • Quality Improvement: Public reporting encourages healthcare organizations to continuously monitor and improve their performance, leading to enhanced patient outcomes and overall healthcare quality.
4. Procedures for Staff Nurses to Achieve Compliance:
   • Staff nurses would need to implement several procedures to achieve compliance with the discharge process for HF patients:
     • Ensure thorough patient education and counseling regarding diet, fluid restriction, activity level, medication management, and recognition of HF symptoms.
     • Document patient teaching and understanding of discharge instructions accurately in the electronic health record.
     • Collaborate with interdisciplinary team members (e.g., physicians, pharmacists, case managers) to coordinate follow-up appointments and ensure continuity of care post-discharge.
     • Regularly assess patient progress and adherence to discharge instructions during hospitalization and provide additional support or reinforcement as needed.
     • Participate in quality improvement initiatives and performance monitoring activities to identify areas for improvement and implement evidence-based practices to enhance discharge processes and patient outcomes.

Anita is admitting a 76-year-old patient with severe cardiomyopathy for recurrent pneumonia. During the admission, the patient, tells Anita that she lives alone with her two cats but has been having trouble lately going up the stairs to the only bathroom in the house. Knowing that the patient’s heart condition will only get worse, Anita questions the patient about the type of house she lives in, how many stairs are in the home, whether any family or friends live nearby, and how she feels about her ability to care for herself living alone. The patient states that she has never been married and has no children. She has some friends who live nearby, but the youngest ones are in their late 70s. Anita is concerned about the patient’s ability to care for herself after discharge, and she informs the physician when he makes his rounds. The physician orders extended care placement for the patient after discharge, full lab work, bronchoscopy, sputum sample, echocardiography, CT scan of the chest, and daily chest x-rays for 3 days. Use the Nursing Today textbook for your responses and cite reference:1.(with reference cited) how did Anita advocate for her patient?2. What concerns should Anita have regarding the information obtained during admission?3. Which issues of fiscal responsibility, if any, are raised by the physician’s orders?4. During discharge, Anita reviews the list of new medications prescribed for the patient. Almost every medication the patient was previously taking has changed in dose or has been replaced by a different medication. What can Anita do to ensure that the patient has the means to obtain the new medications and that she understands how to take them?

Solution

1. Anita’s Advocacy for her Patient:
   • Anita advocates for her patient by proactively assessing the patient’s living situation, functional status, and support network during the admission process. Recognizing potential challenges the patient may face upon discharge, Anita communicates her concerns to the physician, advocating for the patient’s well-being and ensuring appropriate care planning.
   • Anita’s actions align with the nursing role of patient advocacy, which involves promoting patients’ rights, preferences, and safety throughout the healthcare experience (Taylor, Lillis, Lynn, & LeMone, 2019, p. 39).
2. Concerns Regarding Admission Information:
   • Anita should be concerned about the patient’s ability to safely manage activities of daily living, such as climbing stairs to access the bathroom, especially considering her worsening cardiomyopathy and recurrent pneumonia.
   • Additionally, the patient’s lack of immediate family support and reliance on elderly friends raise concerns about her social support network and potential challenges in receiving assistance with activities such as transportation, medication management, and household tasks after discharge.
3. Fiscal Responsibility Issues:
   • The physician’s orders for extensive diagnostic testing (bronchoscopy, echocardiography, CT scan, daily chest x-rays) raise concerns about the cost-effectiveness of care and the appropriate utilization of healthcare resources.
   • Anita may need to consider the financial implications of these orders, advocate for cost-conscious care decisions, and collaborate with the healthcare team to ensure that the patient receives necessary diagnostic evaluations while minimizing unnecessary testing and associated expenses.
4. Ensuring Medication Access and Understanding:
   • To ensure that the patient has the means to obtain new medications and understands how to take them, Anita can take several steps:
     • Collaborate with the hospital’s pharmacy or social work department to assist the patient in accessing affordable medication options, such as patient assistance programs or prescription discount cards.
     • Provide comprehensive medication education to the patient, including instructions on medication administration, potential side effects, and the importance of adherence to the prescribed regimen.
     • Facilitate communication between the patient and her healthcare providers to address any questions or concerns about the medication changes and ensure continuity of care post-discharge.

Reference: Taylor, C., Lillis, C., Lynn, P., & LeMone, P. (2019). Fundamentals of Nursing: The Art and Science of Person-Centered Care (9th ed.). Wolters Kluwer.

A patient at your hospital is sent to cardiology department for a routine test. The patient returns without incident, and you document the time and condition of the patient on return to the room. The next day, you are summoned to the unit manager’s office, along with the charge nurse and unit secretary. The manager describes how the patient was given a dose of Glucophage the morning of the test. The physician wrote an order to hold the Glucophage for 2 days prior to the test because of contraindications between the medication and the intravenous contrast dye. The manager wants an explanation for the incident because controls are in place due to similar incidents on the unit, that should flag the medication, requiring the nurse to hold the medication prior to the test. Use the Nursing Today textbook for your responses and cite reference:

1. What is a root cause analysis (RCA) and who is responsible to complete the RCA in this case? 

2. How would a root cause analysis be conducted to determine the cause of the problem? Who would you include?

3. The hospital has a nonpunitive policy for mistakes and errors. How does this affect the RCA if the cause of the problem is identified as a mistake by the unit secretary?

4. Which TJC patient safety goal was addressed in this case study?

Solution

1. Root Cause Analysis (RCA):
   • A root cause analysis (RCA) is a systematic process used to identify the underlying causes of adverse events or near misses in healthcare settings. It aims to uncover the contributing factors that led to the incident rather than focusing solely on the immediate actions or individuals involved.
   • In this case, the responsibility to complete the RCA would likely fall on a multidisciplinary team comprising representatives from various roles involved in patient care, such as nurses, physicians, pharmacists, and unit secretaries, under the guidance of hospital management or quality improvement personnel.
2. Conducting the RCA:
   • The RCA process typically involves several steps, including gathering data, identifying contributing factors, determining root causes, and developing corrective actions to prevent recurrence.
   • In this scenario, the RCA team would review the patient’s medical records, medication orders, nursing documentation, and any relevant policies or protocols related to medication administration and test preparation.
   • The team would include individuals directly involved in the incident (e.g., nurse who administered the medication, unit secretary who failed to flag the medication order), as well as other staff members who may provide insights into system failures or breakdowns (e.g., charge nurse, pharmacy staff).
3. Nonpunitive Policy and RCA:
   • A nonpunitive policy for mistakes and errors promotes a culture of transparency, accountability, and learning from adverse events without fear of retribution or blame.
   • In the context of conducting an RCA, a nonpunitive approach encourages open communication and collaboration among team members, facilitating the identification of root causes and implementation of effective corrective actions.
   • If the cause of the problem is identified as a mistake by the unit secretary, the focus would be on understanding why the mistake occurred and identifying system-level factors (e.g., inadequate training, unclear procedures) that may have contributed to the error, rather than assigning blame to the individual.
4. TJC Patient Safety Goal:
   • The patient safety goal addressed in this case study relates to medication management and patient safety. Specifically, it aligns with The Joint Commission’s (TJC) goal to reduce the risk of harm associated with the use of medications, which includes ensuring the safe use of high-alert medications and implementing processes to prevent medication errors.

You decide to investigate facilities near your home for possible employment. Each of the following institutions has a unique approach to health care, offering varied employment opportunities.

A. Hospital A is a small community facility with Magnet designation. As you look at the organizational chart, you note that there is a unit manager (UM) who reports to the division director (DD), who then reports to the director of nursing (DON). You also note that control over nursing resides primarily with the DON, including policies, procedures, and any changes affecting nursing practice. You also note the participants in quality improvement include nurses from a variety of practice areas.

B. Hospital B is a facility with a well-known sports clinic. Athletes from all over the state travel to the clinic, which is housed next to the hospital. Although the facility is a typical hospital, whenever anyone mwntions Hospital B, the first thing that comes to mind is the sports clinic. The hospital has implemented a new policy where they only hire baccarlaureate-prepared nurses and provide reimbursement for current nurses who return to school for a baccalaureate degree.

C. Hospital C is a medium-sized facility serving a wide range of patients in the surrounding communities. They have a strong recruitment program for nurses, which includes a residency program. You note that the hospital’s organizational chart has a nurse as the vice president of Client Care Services. You also realize that the unit managers report directly yo the VP and have the authority to make decisions and create policies.

   1. Which type of health care organization is represented by each of the three hospitals?

   2. How would Hospital C benefit a new highly motivated nurse who hopes to have authority?

   3. How could Hospital A benefit a new nurse with no experience in health care?

   4. How are each of the hospitals implementing the recommendations from the Instsiute of Medicine's Report on the Future of Nursing?

   5. Review current position descriptions for a registered nurse in the newspaper or online. How does the description meet the IOM recommendation that nurses to the full extent of their educational preparation? What suggestions would you give for supporting this recommendation?

Solution: Types of Health Care Organizations:

Types of Health Care Organizations:

• Hospital A: Community hospital with Magnet designation, focusing on quality nursing care and excellence in patient outcomes.
• Hospital B: General hospital with a renowned sports clinic, emphasizing specialized care for athletes.
• Hospital C: Medium-sized facility with a wide patient base, prioritizing nursing leadership and development.

Benefits for a New Nurse at Hospital C:

• Hospital C, with a nurse as the vice president of Client Care Services and unit managers having decision-making authority, offers a conducive environment for a highly motivated nurse who aspires for authority.
• New nurses can learn directly from nursing leadership, gaining insights into decision-making processes and having opportunities to contribute to policy development.

Benefits for a New Nurse at Hospital A:

• Hospital A, with a strong emphasis on Magnet designation and quality improvement involving nurses from various practice areas, can benefit a new nurse with no prior experience.
• The collaborative environment and involvement in quality improvement initiatives provide a supportive setting for learning and professional growth.

Implementation of IOM Recommendations:

• Hospital A: Fosters nursing excellence through Magnet designation, which aligns with the IOM’s emphasis on creating environments that attract and retain well-educated nurses.
• Hospital B: By requiring baccalaureate-prepared nurses, Hospital B supports the IOM’s recommendation to increase the proportion of nurses with higher education.
• Hospital C: Empowering nurses through leadership roles and decision-making authority aligns with the IOM’s call for nurses to be full partners in healthcare leadership.

Position Descriptions and IOM Recommendations:

• Position descriptions for registered nurses should emphasize utilizing the full extent of their educational preparation, including critical thinking, decision-making, and leadership skills.
• Suggestions for supporting this recommendation include providing opportunities for continued education, mentorship programs, and career advancement paths for nurses to pursue higher levels of education and leadership roles.
• Descriptions should highlight responsibilities that align with IOM’s recommendations, such as involvement in care coordination, patient education, and quality improvement initiatives. Additionally, job postings could explicitly mention the organization’s commitment to supporting nurses in advancing their education and career development.

A local hospital is promoting their new clinical documentation system and electronic medical health records as a cost containment tool that will improve communication among health care workers, support the delivery of safe patient care, and facilitate the delivery of high-quality patient care. The hospital describes the system as effective in reducing costs by decreasing variability and standardizing care processes. When reviewing outcome data from the hospital on the publicly reportable data website, https://www.medicare.gov/hospitalcompare/search.html

the outcomes for heart failure, surgical, and pneumonia patients are higher than the national average and much higher than at other hospitals in the area.

1. Which elements of cost containment is the hospital demonstrating?
2. How could the use of case managers help reduce the poor patient outcomes, heart failure, surgical and pneumonia patients?
3. Which of the patient populations (heart failure, surgical, pneumonia) might be suited for a disease management program? Describe the population selected and specify why this population is vulnerable. Use an Internet search if needed to support your response. 
4. What are the risks to the hospital if their performance does not improve in the areas of heart failure, surgical or pneumonia outcomes?

Solution

Elements of Cost Containment Demonstrated by the Hospital: The hospital is demonstrating several elements of cost containment through its promotion of the new clinical documentation system and electronic medical health records:

1. Decreasing Variability and Standardizing Care Processes: By implementing the new system, the hospital aims to standardize care processes, which can reduce unnecessary variations in treatment approaches and potentially decrease costs associated with redundant or ineffective treatments.
2. Improving Communication Among Healthcare Workers: Effective communication among healthcare workers can lead to better coordination of care, which can prevent costly medical errors and unnecessary procedures.
3. Supporting Safe Patient Care: A focus on safe patient care can help prevent adverse events that could lead to costly complications or readmissions, thereby reducing overall healthcare costs.
4. Facilitating High-Quality Patient Care: High-quality care not only improves patient outcomes but can also lead to cost savings by reducing the need for additional interventions or treatments to address complications.

Use of Case Managers to Improve Patient Outcomes: Case managers play a crucial role in coordinating care for patients, especially those with complex medical conditions such as heart failure, surgical, and pneumonia patients. They can help reduce poor patient outcomes by:

• Coordinating care transitions: Case managers can ensure smooth transitions between different levels of care, reducing the risk of complications or gaps in treatment.
• Monitoring and managing care plans: Case managers can closely monitor patients’ progress, ensuring adherence to treatment plans and timely interventions to address any issues that arise.
• Providing patient education and support: Case managers can educate patients about their conditions and self-care strategies, empowering them to manage their health effectively and prevent complications.
• Facilitating communication among healthcare providers: Case managers act as liaisons between different members of the healthcare team, ensuring that relevant information is shared and coordinated effectively.

Suitability of Disease Management Programs: The heart failure patient population would be well-suited for a disease management program. Heart failure is a chronic condition characterized by frequent exacerbations and hospitalizations, making it particularly vulnerable to poor outcomes without adequate management. A disease management program for heart failure patients could include:

• Regular monitoring of symptoms and vital signs to detect early signs of decompensation.
• Optimization of medication regimens to reduce symptoms and prevent hospitalizations.
• Patient education on diet, exercise, and medication adherence to promote self-management and reduce the risk of exacerbations.
• Coordination of care between primary care providers, cardiologists, and other specialists to ensure comprehensive management of the condition.

Risks to the Hospital if Performance Does Not Improve: If the hospital’s performance does not improve in the areas of heart failure, surgical, or pneumonia outcomes, several risks may arise:

• Financial penalties: Poor performance on publicly reported quality measures can result in financial penalties from payers such as Medicare and Medicaid.
• Reputation damage: Persistently high rates of adverse outcomes can damage the hospital’s reputation and erode patient trust, leading to decreased patient volumes and revenue.
• Legal liabilities: Poor patient outcomes may expose the hospital to legal liabilities, including malpractice claims and regulatory scrutiny.
• Loss of accreditation: Accrediting bodies may take action against the hospital if it fails to meet established quality standards, leading to loss of accreditation and eligibility for reimbursement from certain payers.

In conclusion, the hospital’s promotion of its clinical documentation system and electronic medical health records demonstrates a commitment to cost containment through standardizing care processes, improving communication among healthcare workers, and supporting safe, high-quality patient care. Utilizing case managers and implementing disease management programs can help reduce poor patient outcomes and improve care coordination for vulnerable populations such as heart failure patients. However, failure to improve performance in key outcome areas poses significant risks to the hospital, including financial penalties, reputational damage, legal liabilities, and loss of accreditation.ShareSave