Running head: QUALITY IMPROVEMENT PROCESS

Quality Improvement Process Karilyn Bufka Ferris State University

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QUALITY IMPROVEMENT PROCESS

2 Abstract

Quality improvement teams work towards improving patient outcomes or nursing sensitive issues in all settings, not just hospitals (Yoder-Wise, 2011). Interdisciplinary teams are formed and strategies are implemented to help determine goals for specific outcomes. With the classification as a “never event” by Medicare and Medicaid, hospitals no longer receive funding for care related to falls (Miller, 2009). This paper uses the steps outlined by Yoder-Wise (2011) in a simulation of a quality improvement team working towards decreasing the fall rate in a hospital setting.

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Quality Improvement Process Quality and safety are two standards that must be achieved in acute care settings. Quality improvement programs help to identify consumers’ needs, assemble a team, collect data, establish outcomes, discuss plans, and evaluate the progresses made (Yoder-Wise, 2011). Quality improvement has become very important to ensure maximal reimbursement from health insurance companies. According to Yoder-Wise (2011) another benefit is possibly reducing malpractice suits. Although quality management can be costly, the improvements that can be made outweigh the costs. Leaders of the quality management team must work together effectively if this is to happen. Keeping an open mind, including all disciplines involved, and continued support and analysis are essential for a positive outcome. Clinical Needs Falls among inpatient hospital patients are unfortunately a common occurrence and are costly for hospitals. In 2008, the Center for Medicare and Medicaid Services listed falls as a “never event” and no longer reimburses hospitals for services related to the fall (Miller, 2009). A quality improvement project that has a goal of reducing falls for inpatient areas is therefore of utmost importance. Nursing literature has found that patient falls are one of the most commonly reported adverse events in hospitals, with more than one million occurring annually in the United States alone (Mion et al., 2012). Considering that number, the malpractice suits and injuries could cost hospitals millions of dollars each year. Reducing or eliminating falls will help hospitals reduce running costs in a time when cost containment is essential.

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Interdisciplinary Team When considering falls, many different practices need to be included on the quality improvement team. Nursing and unlicensed assistive personnel (UAP) are the first that comes to mind, but other departments are equally important. Pharmacy should be included as medications may increase risk of falling. Physical and occupational therapy work directly with patients and need to be included, as they can also provide assistance in preventing falls to educate nurses and UAP how to properly transfer patients. Janitorial and housekeeping should be included due to their continuous presence in patient care areas. Nurse management and floor managers should also be involved as policies and procedures may need to be updated throughout the process. Physicians should also be included in the team process and data analysts are also important. Administrative personnel should be given the opportunity to participate as well. Financial incentives are something that can help get the staff’s attention and perhaps increase employee compliance with any changes that are made to policies and procedures. They have been used previously in quality improvement processes for falls (Ohde et al., 2012). Date Collection Method Before data collection can start, the team should determine a definition of a fall. A literature review by all involved should assist in this task. This is an important stage to ensure everyone is on the same page before data collection begins. Data collection for fall prevention quality improvement teams should include a chart audit of current and past patients. The data analysis specialist(s) on the team should analyze the data and determine if there are trends of patient falls. Cross referencing with the nurse to patient ratios at the time of the fall may be important. Intrinsic (physiologic) and extrinsic (environmental) factors should be considered (Pearson & Coburn, 2011).

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A detailed flowchart should be created following the steps of patients from admission all the way to discharge. Yoder-Wise (2011) states that going through these steps may lead to the acknowledgement of gaps that lead to opportunities for improving care. In my current agency, falls are reported on incident reports that are turned in to nurse managers. These reports should be analyzed by all members of the quality improvement team. Data should be analyzed to present a summary of falls on a spreadsheet that would include information such as where the falls took place, staff present, etc. Presenting the information in a comprehensive form will help the team determine what areas need to be assessed and what types of changes are needed. Outcomes After data collection, an outcome for the quality improvement team must be determined. According to Yoder-Wise (2011), the outcome should “involve a standard of practice and a measurable patient-care outcome or nursing-sensitive outcome” (p. 399). In this process, the current rate of patient falls should be determined. According to the Agency for Healthcare Research and Quality (n.d.), an appropriate outcome would be to lower the current fall rate. This outcome would be measurable due to data collection from charts and incident reports. The process of benchmarking could be used to help determine the rate of falls in similar hospitals and the processes of those hospitals (Yoder-Wise, 2011). Comparing to hospitals with similar patients and number of beds would help determine an appropriate number for the fall rate reduction outcome. Implementation Strategies The quality improvement team must discuss the data and determine the best way to implement strategies to meet the outcome. Prior studies that have been conducted must be

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analyzed to determine the evidence based practice that has shown to decrease fall rates in other institutions. The team must stress to those implementing the strategies that they are trying to improve the system and not place blame on employees for previous falls so staff can have open communication with the team (Yoder-Wise, 2011). Staff involvement has been shown to be crucial in lowering falls in hospitals (Ohde et al., 2012). Including mandatory staff education and assessments on new tools is essential. It was mentioned previously that financial incentives have been used to decrease falls (Ohde et al., 2012) and this is something that would have to be approved by administration, but it may be explored to help ensure staff compliance with new policies. Nurse managers and leaders on the floor can be trained by the quality improvement team as super-users to help increase compliance of floor nurses. A major implementation should be creating a fall risk assessment tool used on admission for all patients. This will help determine the patients who are at the greatest risk for falling and can then be highlighted as such through the use of wristbands, signs, etc (Ohde et al., 2012). Information on falls can be handed out to those individuals and their families. Patients that are identified as fall risks can then have tasks implemented such as toileting regimes, bed alarms, and medication reviews by pharmacy and physicians to help reduce their chance of a fall (Pearson & Coburn, 2011). Nurse management and leaders may need to update policies and procedures for incorporation of the fall risk assessment tool in admission processes. Evaluation Evaluation is something that is ongoing and starts from the beginning of the program, while it is being implemented, and after the program has been completed (National Center for Injury Prevention and Control, 2008). The quality improvement team must continue to meet and

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assess the outcomes of the interventions implemented while the project is going on. If improvements have not been made, the programs should be reviewed and changes must be made (Yoder-Wise, 2011). This may mean that the team must start from the beginning and adjust outcomes and interventions. Analysis should be conducted in qualitative and quantitative form (National Center for Injury Prevention and Control, 2008). Qualitative forms would include following up on incident reports by interviewing staff and patients involved in falls (Hitcho et al., 2004). Quantitative forms are information in number form, such as the number of falls occurring over a certain period of time, as determined from incident reports and chart audits. If improvements have been made and the outcomes have been met, the quality improvement team may disband upon direction from administration. However, some hospitals now have permanent quality improvement teams that meet regularly to focus on improvements in specific patient care (Yoder-Wise, 2011). In the case of fall prevention, if the fall ratio has been decreased to that as determined in the outcome, the facility will have to determine whether or not they want to continue the quality improvement team. Conclusion Quality improvement is something that includes nurse leaders and is dependent on the organization working together in an interdisciplinary team to improve a determined outcome. Since Medicare and Medicaid no longer pay for injuries sustained from hospital falls (Miller, 2009), it is imperative that hospitals implement quality improvement teams to help decrease falls. Using the steps of the quality improvement process as outlined by Yoder-Wise (2011), hospitals can help decrease costs associated with falls to help them remain financially viable.

QUALITY IMPROVEMENT PROCESS

8 References

Agency for Healthcare Research and Quality (n.d.). Acute care prevention of falls: Rate of inpatient falls with injury per 1,000 patient days. Retrieved from http://www.qualitymeasures.ahrq.gov/content.aspx?id=27680 Hitcho, E. B., Krauss, M. J., Birge, S., Dunagen, W. C., Fisher, I., Johnson, S., Nast, P. A., Costantinou, E., & Fraser, V. J. (2004). Characteristics and circumstances of falls in a hospital setting. Journal of General Internal Medicine, 19(7), 732-739. doi: 10.1111/j.1525-1497.2004.30387.x Miller, A. (2009). Hospital reporting and “never events”. Medicare Patient Management, May/June 2009. Retrieved from http://www.medicarepatientmanagement.com/issues/0403/mpmMJ09-NeverEvents.pdf Mion, L. C., Chandler, A. M., Waters, T. M., Dietrich, M. S., Kessler, L. A., Miller, S. T., & Shorr, R. I. (2012). Is it possible to identify risks for injurious falls in hospital patients? Joint Commission Journal on Quality and Patient Safety, 38(9), 408-413. National Center for Injury Prevention and Control. (2008). Preventing falls: How to develop community-based fall prevention programs for older adults. Retrieved from http://www.cdc.gov/homeandrecreationalsafety/images/cdc_guide-a.pdf Ohde, S., Terai, M., Oizumi, A., Takahashi, O., Deshpande, G. A., Takekata, M., Ishikawa, R., & Fukui, T. (2012). The effectiveness of a multidisciplinary QI activity for accidental fall prevention: Staff compliance is critical. BMC Health Services Research, 12. doi: 10.1186/1472-6963-12-197

QUALITY IMPROVEMENT PROCESS Pearson, K. B., & Coburn, A. F. (2011). Evidence-based falls prevention in critical access hospitals. Retrieved from http://flexmonitoring.org/documents/PolicyBrief24_FallsPrevention.pdf Yoder-Wise, P. S. (2011). Leading and managing in nursing (5th ed.). St. Louis, MO: Elsevier Mosby.

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