Prepare an evaluation (5-7 pages) of an existing QI initiative to

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Quality Improvement Initiative Evaluation

Susie Mayo

Capella University

MSN FP-6016

Dr. Carolyn Morrisey

September 2020

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Quality Improvement Initiative Evaluation

Patient safety is a priority in any healthcare setting. Hospitals utilize quality improvement

(QI) initiatives to improve the quality of patient care, deliver the highest level of quality care to

our patients safely, focus on patient health outcomes while attaining cost efficiencies. The

purpose of the Quality Improvement Initiative is to first focus on patient safety and to foster a

deliberate and thoughtful approach to the provision of services by providing a common

framework for measurement, assessment, improvement, and maintenance of performance in

accordance with the corporation's mission, vision, and values (Ohio Health, 2020). Healthcare

acquired infections (HAIs) are infections patients get in the hospital while receiving care for

another condition. The U.S. Department of Health and Human Services (HHS) (2020) states,

"the HHS has identified the reduction of HAIs as an Agency Priority Goal and is committed to

reducing the national rate of HAIs" (para.4-5).

Analyze Current Quality Improvement Initiative

Infection control and prevention interventions are at the core of the safe care concept, and

understanding a process before attempting to improve it is critical in any quality improvement

initiative. Common HAIs that patients get in hospitals include central-line associated

bloodstream infections (CLABSI), clostridium difficile (c-diff) infections, pneumonia (PNA),

methicillin-resistant Staphylococcus aureus (MRSA) infections, surgical site infections, with

catheter-associated urinary tract infections (CAUTI) the most common of HAIs(The Center for

Diease Control, 2019).

The Ohio Health organization has infection prevention policies that are OhioHealth

hospital-specific policies. Ohio Health implemented a CAUTI prevention bundle, within policy

and procedures, that consists of hand hygiene, wearing personal protective equipment, use of

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disposable gloves, cleansing of urethral meatus before catheter insertion using sterile saline,

assessment of catheter need, aseptic urine sampling technique, and correct draining bag

positioning(Ohio Health, 2017). The Committee on Hospital Infection Prevention (CHIP)

oversees the planning, organization, development, and evaluation of the hospital-wide infection

control program for all Ohio Health hospitals based on the guidelines of The Joint

Commission(Ohio Health, 2017). The goal is to minimize the hazards of healthcare-associated

infections and infection potentials by instituting and maintaining measures for the prevention,

investigation, reporting, and control of infections. The neurocritical care (NCC) and intensive

care unit (ICU) population is at exceptionally high risk for catheter-associated urinary tract

infections (CAUTIs) due to length of stay, chronic disability, immobility, agitation, and

confusion(Busl, 2019). These units tend to have higher CAUTI rates in the United States (U.S.)

than other patient care units(Busl, 2019). Ohio Health NCC and ICUs have QI guidelines in

place for CAUTI prevention, but omit some of the causes that can lead to CAUTI(Ohio Health,

2017). The Center for Disease Control (CDC) (2019) reports, "many of these infections are

preventable, and common reasons that lead to HAIs are an improper use of catheters, such as

convenience, a break in sterile technique inserting a foley, improper hygiene and handwashing

by hospital staff spreading germs and bacteria from other hospitalized patients and understaffing,

which can lead to patients not receiving the attention they need for foley care leading to infection

and worsening health(pp.34-41 ).

Recognized Benchmarks and Outcome Measures

The National Healthcare Safety Network(NHSN) is the nation's most widely used

healthcare-associated infection(HAI) tracking system. Since 2009, infection data has been

reported to the NHSN to track the national progress of reducing HAIs(The U.S. Department of

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Health and Human Services,2020). Ohio Health follows guidelines set forth by The Joint

Commission and the CDC for the prevention of HAIs (G.Howard, personal communication,

September 17, 2020). Ohio Health completes monthly reporting plans, and collected outcome

data is entered using their Center for Medicare & Medicaid Services (CMS) Certification

Number (CCN), which is then sent directly to the NHSN HAIs tracking system(G. Reid,

personal communication, September 17, 2020). The Ohio Health NCC is compared to other

neurocritical care units(NCC) with > 15 beds in hospitals with > 500 beds, and the data is

calculated taking the number of foleys per 1000 patient days, so this accounts for our actual size

of 32 beds(G.Howard, personal communication, September 17, 2020). The expected number of

CAUTIs from July 2017 – February 2018 was 17, and Ohio Health's NCC had 32; this is about

two extra infections per month. The expected number of foley days from July 2017 – February

2018 was 3980, and the NCC had 4858, which is about 98 extra foley days a month(G. Howard,

personal communication, September 17, 2020). These numbers revealed CAUTI was higher

than the national benchmarks( (G. Howard, personal communication, September 17, 2020).

Education was heightened on the NCC unit to monitor proper hand hygiene, use of foaming

stations outside of rooms, and adequate patient foley catheter care( G.Howard, personal

communication, September 17, 2020). The Agency for Healthcare Research and Quality(AHRQ)

(2015) recommends, "units identify the number of symptomatic CAUTIs attributable each

month, the CAUTI rate, and days since last CAUTI as metrics for outcome measures, so the

patient care team and administrators will be able to use NHSN data for benchmarking purposes"

(para.6-8). The AHRQ(2015), further states, "comparing your unit's CAUTI rate with other units

of the same patient type and acuity gives the team "apples to apples" information about how their

patient outcomes compare to other units" (para.8).

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Interprofessional Perspectives related to Initiative Functionality and Outcomes

Interprofessional collaboration is critical in promoting quality and safe patient care and is

fundamental for successfully delivering patient-centered care. A team approach ensures that

healthcare personnel and others who take care of catheters are given periodic in-service training

regarding techniques and procedures for urinary catheter insertion, maintenance, and

removal(Ohio Health, 2017). Provide education about CAUTI, other complications of urinary

catheterization, and alternatives to indwelling catheters. The CDC (2017) reports," this builds

consensus on current process strengths and shortcomings, and also creates team recognition of

areas of improvement targeted to a process and not at people(para.11). Ohio Health has

incorporated the CAUTI Workgroup, OhioHealth Nursing Policy, and Procedure Committee that

includes NCC, ICU nurse managers, clinical educators, chief nursing officer(CNO), and the Ohio

Health medical director(G. Howard, personal communication, September 17, 2020). The Ohio

Health CAUTI workgroup follows recommendations set forth by Refer to Perry and Potter's

Clinical Nursing Skills reference text for specific care instructions, The Joint Commission, and

the CDC(G. Howard, personal communication, September 17, 2020). This writer conducted

personal telephone communication with Gina Howard, MSN, director of Ohio Health Riverside

Methodist Hospital NCC. Gina Howard provided this writer with information about their unit

studies on CAUTI due to the patient population and the higher incidence of CAUTIs in the NCC.

This writer located policy and procedure from the Ohio Health employee websites.

Additional Indicators and Protocols to Improve/Expand Quality Outcomes

The AHRQ has initiated a Toolkit To Reduce CAUTI and Other HAIs in Long-Term Care

Facilities. This toolkit helps long-term care (LTC) facilities reduce catheter-associated urinary

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tract infection (CAUTI) and improve practices to prevent healthcare-associated infections (HAIs)

(Agency for Healthcare and Quality, 2015). The toolkit was developed during a 3-year project

that involved a national quality improvement collaborative designed to reduce CAUTIs and

enhance patient safety culture and practices in LTC facilities and provides resources to enhance

leadership and staff engagement, teamwork, and safety culture, to facilitate consistent use of

evidence-based practices(Agency for Healthcare and Quality, 2015). Ohio Health utilizes a

CAUTI prevention bundle and still found gaps in care such as breaks in sterile technique

inserting a foley, improper hygiene, and handwashing by hospital staff, and lack of proper care

due to understaffed units. The Toolkit To Reduce CAUTI and Other HAIs in Long-Term Care

Facilities may offer new protocols to improve and expand quality outcomes of the Ohio Healths

CAUTI quality initiative. Other specific process or protocol changes that may be beneficial

would be a two registered nurse(RN) insertion checklist. The purpose of the second RN is to

watch the primary RN's sterile technique. This specific process would hold staff accountable for

following a specific protocol. Both nurses would document their names in a CAUTI detailed

document.

Conclusion

The creation of care bundles was one of the innovations to ensure a set of standard

interventions was performed in 100% of the patients. Even with the implementation of bundles,

team leaders and staff members must be diligent with the protocols and processes to reduce the

number of patients at risk for HAIs. Health care professionals need to be engaged in their patient

care and make care safer by following clinical best practices and creating a culture of safety.

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References

Agency for Healthcare Research and Quality. (2015). Toolkit for reducing catheter-associated

urinary tract infections in hospital units: implementation guide.

https://www.ahrq.gov/hai/cauti-tools/guides/implguide-pt4.html

Busl, K. (2019). Healthcare associated infections in the neurocritical care unit. Current

Neurology and Neuroscience Reports. Springer Link. https://doi.org/10.1007/s11910-019-

0987

CDC. Healthcare infection control practices advisory committee. (2019). Guideline for

prevention of catheter-associated urinary tract infections 2009 [PDF]. Center for Disease

Control.. https://www.cdc.gov/infectionconrol/pdf/guidelines/cauti-guidelines-H.pdf

Ohio Health. (2017). Committee on Hospital Infection Prevention. Policy and Procedure.

https://ohesource.ohiohealth.com/departments/clinicalqualitysafety/CAUTI

Ohio Health. (2020). Process Improvement and Patient Safety Plan. Policy and/or Procedure.

https://ohesource.ohiohealth.com/infocentral/CareConnect/careprocess_improvement_an

d_patient_safet_plan

U.S. Department of Health and Human Services. (2020). Healthcare Associated Infections.

https://health.gov/our-work/health-care-quality/health-care-associated-infections

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Quality Improvement Initiative Evaluation

Student’s Name:

Course Name:

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Introduction

In healthcare settings, plans for process-specific quality improvement are frequently

reactive and focused on actions to improve a single process. Harmful incidents or near-misses

will serve as a wake-up call for many healthcare organizations when patient well-being is a

priority, inspiring activities to enhance care. Quality improvement projects that concentrate

on particular issues must be carefully planned to elevate the level of care and expand patient

safety. The primary focus of this paper is the quality program implemented in the author's

healthcare association to diminish pharmaceutical errors and improve healthcare safety. To

prevent pharmaceutical errors, interprofessional teams work together to pinpoint the root

causes of mistakes and implement preventative measures.

An examination of a contemporary QI project

Medication errors were common in the healthcare organization before initiating the

quality improvement (QI) program. Two mistakes that seriously hurt patients and were

exposed to the media caused the organization to face a lot of criticism. A QI program that

focuses on the issue of pharmaceutical errors was developed in response to these complaints

and the requirement to improve healthcare outcomes. Due to the high rates, a program was

established. Its primary goal was to address the causes of errors that were already occurring

to increase patient safety by reducing error rates.

The hospital board established a QI committee to begin a QI project in response to

medicinal errors. Clinical personnel, office employees, and QI coordinators made up the

interdisciplinary QI committee. Identifying the underlying causes of quality issues was the

first stage in testing, putting solutions into practice, and assessing the results. Although the

committee was established to provide a backing for overall quality, pharmaceutical errors

were its main area of interest. The Pharmaceutical Error Prioritization System (MEPS), a

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system for recording and categorizing drug errors within the healthcare system, was created

by the committee in response to medication errors. These two strategies summarize the

committee's efforts to decrease pharmaceutical errors and improve patient safety.

Even though the effort generally reduced errors, doctors found it difficult to

implement. Many doctors chose to write traditional paper-based prescriptions instead of using

the convoluted and poorly developed e-prescription system. However, changes were made

that made the system easier to use. The QI program did not look into patient experiences and

how they affect the likelihood of drug errors. Patients did not immediately benefit from the

MEPS program because it is only available to staff, even though it improved reporting and

tracking. Due to fewer drug errors, the QI effort may not have improved patient safety as

successfully as it could have. The healthcare organization must make changes to increase user

access to the QI and gather patient experiences.

Analyze a current QI initiative's performance.

The QI initiative was successful in part because fewer errors were made. Frequency

measurement is the primary yardstick for assessing quality improvement in pharmaceutical

mistakes. A 20% decrease in the reported number of medication errors was seen when

comparing medication error rates six months before and after the QI project was

implemented. Despite a trend in the right direction, it's unclear whether reporting stayed the

same. Control for reporting rates is one of the main obstacles to evaluating the efficacy of

medication error reduction, according to Donaldson et al. (2017). Perhaps fewer practitioners

than in the past have reported medication errors. The QI initiative successfully lowered the

frequency of drug errors in the company, assuming that reporting remained consistent before

and after the effort.

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Second, the method lowered the percentage of pharmaceutical errors that led to both

temporary and severe injuries. The hospital divides errors that cause no harm, inconsequential

harm, severe harm, or death into three categories. Before the experiment, 30% of all reported

errors only resulted in temporary damage in 3% of cases and severe harm in only 1% of

cases. 90% of all issues had been resolved without putting patients in danger after the project

had been in place for six months. The effort improved patient safety overall by lowering the

percentage of errors that hurt patients. It is predicted that reporting rates will remain constant

before and after the program, just like the previous benchmark.

New metrics could be added to the existing metrics to assess the project's success and

how effectively the technique was performed to increase patient safety. First, we must

ascertain the reporting rates. Practitioners must operate in a setting where reporting and

correcting errors is encouraged if the objective is to increase patient safety by minimizing

prescription errors (Morrison, Cope, & Murray, 2018). It must be a setting that encourages

higher reporting rates and is victim-free. It is necessary to have a system in place for

evaluating how well reporting is done within the company. Second, customer reviews would

benefit the business, particularly regarding how happy customers are with the healthcare

system. Patient happiness and experience with the healthcare system are closely related to

patient safety. To accurately assess the effectiveness of the QI effort, the organization must

incorporate metrics that measure patients' views of safety and quality.

Perspectives from Various Professions

A multidisciplinary team worked on the QI project and contributed to this analysis.

Clinical staff, support workers, and QI coordinators were part of the interprofessional

strategy, which focused on particular and overall health improvement goals. Members of the

clinical staff, including doctors, nurses, and pharmacists, were the first category of

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professionals to be evaluated. The feedback was primarily concerned with users' opinions of

usability and any issues they had with the QI effort. The rigidity and lengthy procedure of the

computerized prescription system, according to a nurse practitioner (NP), made it difficult to

utilize at first. However, she noted that with improvements and persistence from the

prescribing physician, the system minimized errors compared to paper-based prescription

methods. She stated that although MEPS accurately monitored errors, fewer medication

errors were not necessarily the result of its use. She also thanked the group for considering

clinical staff members' perspectives and experiences when implementing the quality

initiative.

The e-prescription system has received overwhelmingly positive feedback from

support staff and QI coordinators for making identifying and eliminating drug mistakes

easier. The performance of information technology (IT) must live up to expectations, and

support employees are accountable for this. According to their perspective, effective

communication was essential for the initiative's speedy implementation. The IT team utilized

the user interface improvements as an illustration to highlight the value of clinical staff

feedback in enhancing certain system functions. The QI coordinator also spoke about the

importance of fast feedback and communication while keeping track of pharmaceutical

errors. The QI coordinator says that encouraging reporting and fostering honesty is the most

challenging problem.

The interprofessional team's observations revealed that the key issues were staff

reaction, motivation, and communication. The communication perspectives demonstrated that

the system was successful in boosting group efforts to lower pharmaceutical mistakes.

However, identifying problems with the reporting and e-prescription systems requires open

and timely communication. The healthcare organization recognized the pain in the

requirement for a strategy to promote more reporting and gauge reporting rates.

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Additional Protocols and Indicators

More indications, protocols, and technological advancements could help the QI effort.

The first suggested reform is implementing an anonymous reporting process that covers staff

and patients. It is a fundamental tenet of the healthcare system that all reports of drug <

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