IHP 430 Final Project
IHP 430 Final Project Guidelines and Rubric Overview As a student of healthcare quality management, it is vital that you are able to identify problems that arise in healthcare organizations and propose strategies for their improvement. A critical part of this process requires you to be familiar with quality and accreditation standards and navigate the communication channels of the organization. For your summative assignment, you will identify a departmental problem within a healthcare organization and develop a collaborative performance improvement initiative to address it. Ideally, the proposed evidence-based solution will serve to improve the departmental problem, thus contributing to the overall success of the healthcare organization. The project is divided into three milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. These milestones will be submitted in Modules Two, Four, and Six. The final product will be submitted in Module Seven. In this assignment, you will demonstrate your mastery of the following course outcomes: • • • • • Evaluate appropriate methods of healthcare data collection and interpretation for informing organizational decision making Assess healthcare performance improvement initiatives for addressing gaps in organizational performance Evaluate requirements of current quality and safety initiatives for how they promote the culture of safety in healthcare organizations Formulate communication and teamwork strategies in quality management that engage diverse stakeholders within healthcare organizations Evaluate information management systems and patient care technologies that promote healthcare quality Prompt Begin by identifying an organizational problem within your own workplace healthcare setting or a hypothetical healthcare organization. Propose an initiative that addresses this chosen problem, utilizing evidence-based literature and quality standards. If you choose a problem in your workplace, be sure to utilize data from that healthcare organization; if you have created a hypothetical healthcare organization, you may use a public domain database with instructor permission. As this is a scholarly initiative, this assignment must adhere to all APA requirements and formatting and include peer-reviewed and evidence-based sources to support any and all claims. Specifically, the following critical elements must be addressed: I. What Is the Organizational Problem? a) Provide the organizational problem that you have chosen. How does this problem fail to meet quality or other regulatory requirements? b) Articulate organizational challenges posed by the problem (e.g., interdepartmental conflicts, communication failure, budgeting issues). II. Evidence-Based Support 1 a) Provide data that supports the existence of the problem. You may utilize public sources to find data related to your selected problem. b) How has this problem been addressed in the past? What information management systems or patient care technologies have been utilized when addressing this problem? Be sure to use peer-reviewed literature to support your answer. c) Discuss relevant accreditation standards, safety standards, compliance standards, and quality initiatives. How do these standards promote a culture of safety within the department? Be sure to cite the appropriate standards within your answer. III. Performance Improvement Initiative a) Propose an initiative that will address this problem within the department of your chosen healthcare organization. What specific relevant quality standard will this quality initiative address? b) Describe the type of data that will reveal a quality outcome. IV. Implementation of the Plan in the Organization a) How will this implementation plan be communicated among departments? b) How will the data be displayed and shared with the organization? c) If the plan for this initiative was implemented, what do you believe would be the hypothetical effect(s) on patient care outcomes? How will health information systems support those improvements in patient care? d) What do you think the hypothetical effect of the quality or performance plan would be on the culture of safety within the organization? V. Success of the Performance Improvement Plan a) If this initiative is successful, how would the organization monitor the financial implications? b) How would the current information management systems contribute to the success of your plan? c) What current organizational processes will help the plan be successful? d) How will the plan be communicated among departments? How will this communication help team members commit to the performance improvement plan? Milestones Milestone One: Identify Organizational Problem In Module Two, first, you will identify a problem in a healthcare organization. You may use a problem from your organization or a problem from a fictional organization. This milestone is graded with the Milestone One Rubric. Milestone Two: Initiative Proposal In Module Four, you will build upon the work you completed on milestone one. In this milestone, you will propose an improvement plan that focuses on the problem you selected in Milestone One. If you chose a problem in your workplace, be sure to use data from that healthcare organization; if you created a hypothetical healthcare organization, you might use a public domain database with instructor permission. Next, you will develop an implementation plan for the 2 problem that you are focusing on. Then, you will discuss the predicted success of the performance improvement plan after implementation. This milestone is graded with the Milestone Two Rubric. Milestone Three: Implementation of Performance Initiative In Module Six, you will implement your performance improvement plan. Also, you will discuss what success of the performance improvement plan will look like. If you choose a problem in your workplace, be sure to use data from that healthcare organization. If you created a hypothetical healthcare organization, you might use a public domain database with instructor permission. This milestone is graded with the Milestone Three Rubric. Final Submission: Organizational Performance Initiative In Module Seven, you will submit your final project. The final project should be a complete, polished paper containing all of the items listed on the grading rubric. Your paper should show that you have applied all of the instructor feedback. This submission is graded with the Final Project Rubric. Deliverables Milestone Deliverable Module Due Grading One Identify Organizational Problem Two Graded separately; Milestone One Rubric Two Initiative Proposal Four Graded separately; Milestone Two Rubric Three Implementation of Performance Initiative Six Graded separately; Milestone Three Rubric Final Submission: Organizational Performance Initiative Seven Graded separately; Final Project Rubric Final Project Rubric Guidelines for Submission: Your organizational performance initiative should be 8–10 pages in length; however, the quality of this submission is much more important than the length. All resources must be appropriately cited in APA format. Critical Elements Problem: Provide Exemplary (100%) Meets “Proficient” criteria and includes insightful detail about how the problem fails to meet quality or regulatory requirements Proficient (85%) Comprehensively provides details about how the problem fails to meet quality or regulatory requirements 3 Needs Improvement (55%) Provides details about how the problem fails to meet quality or regulatory requirements but with gaps in detail or logic Not Evident (0%) Does not provide details about how the problem fails to meet quality or regulatory requirements Value 4.5 Critical Elements Problem: State Support: Provide Support: Addressed Exemplary (100%) Meets “Proficient” criteria and offers greater depth of information regarding the organizational challenges posed by the problem Meets “Proficient” criteria and data provided demonstrates nuanced understanding of the problem Meets “Proficient” criteria and description includes insightful detail regarding how this problem has been addressed in the past Support: Discuss Meets “Proficient” criteria and offers professional insights concerning how accreditation, safety, compliance, and quality standards promote a culture of safety Performance: Propose Meets “Proficient” criteria and proposal demonstrates a nuanced insight into the relationship between the performance improvement plan and the quality standard being addressed Meets “Proficient” criteria and demonstrates great insight into the type of data that will reveal a quality outcome Performance: Describe Proficient (85%) Clearly states organizational challenges posed by the problem Needs Improvement (55%) States organizational challenges posed by the problem, but articulation is not clear Not Evident (0%) Does not state organizational challenges posed by the problem Value 6 Provides data that supports the existence of the problem Provides data but data does not fully support existence of the problem Does not provide data or data provided does not support existence of the problem 6 Thoroughly describes how this problem has been addressed in the past, including the information management systems or patient care technologies utilized, and supports answer with peerreviewed literature Clearly discusses relevant accreditation, safety, and compliance standards, as well as quality initiatives, including how these standards promote a culture of safety within the department, and cites appropriate standards Proposes a performance improvement plan to address the chosen problem, including the quality standard being addressed Describes how this problem has been addressed in the past but with gaps in detail, and supports answer but support does not include peerreviewed literature or is irrelevant Does not describe how the problem has been addressed in the past or does not support answer 6 Discusses accreditation, safety, and compliance standards, as well as quality initiatives, but with gaps in detail or clarity, and cites standards but citations are irrelevant or inappropriate Does not discuss accreditation, safety, compliance, and quality standards and does not cite standards 9 Proposes a performance improvement plan to address the chosen problem but proposal has gaps in detail or logic Does not propose a performance improvement plan 4.5 Accurately describes the type of data that will reveal a quality outcome Describes the type of data that will reveal a quality outcome Does not describe the type of data that will reveal a quality outcome 6 4 Critical Elements Implementation: Communication Implementation: Data Implementation: Initiative Implementation: Effect Success: Financial Success: Information Exemplary (100%) Meets “Proficient” criteria and description is exceptionally clear in how the implementation plan will be communicated among departments Meets “Proficient” criteria and choices of how the data will be displayed and shared with the organization demonstrate nuanced insight into communication within the chosen healthcare organization Meets “Proficient” criteria and offers reasoning concerning the hypothetical effects of the initiative on patient care outcomes Meets “Proficient” criteria and offers reasoning concerning the hypothetical effect of the quality plan on the culture of safety within the organization Meets “Proficient” criteria and offers reasoning pertaining to how the organization will monitor the financial implications if this initiative is successful Meets “Proficient” criteria and hypothesis demonstrates nuanced insight into the relationship between information management systems and performance improvement initiatives Proficient (85%) Thoroughly describes how the implementation plan will be communicated among departments Needs Improvement (55%) Describes how the implementation plan will be communicated among departments but description has gaps in detail Not Evident (0%) Does not describe how the implementation plan will be communicated among departments Value 6 Accurately describes how the data will be displayed and shared with the organization Describes how the data will be displayed and shared with the organization but description is inaccurate Does not describe how the data will be displayed and shared with the organization 6 Comprehensively describes the hypothetical effects of this initiative on patient care outcomes, including how health information systems support improvements in patient care Comprehensively describes the hypothetical effect of the quality plan on the culture of safety within the organization Describes the hypothetical effects of this initiative on patient care outcomes but description is cursory Does not describe the hypothetical effects of the initiative on patient care outcomes 6 Does not describe the hypothetical effect of the quality plan on the culture of safety within the organization 9 Comprehensively describes the how the organization will monitor the financial implications if this initiative is successful Describes the hypothetical effect of the quality plan on the culture of safety within the organization but description is cursory Describes how the organization will monitor the financial implications if this initiative is successful but description is cursory Does not describe how the organization will monitor the financial implications if this initiative is successful 4.5 Logically hypothesizes how the current information management systems would contribute to the success of this plan Hypothesizes how the current information management systems would contribute to the success of this plan but hypothesis is illogical Does not hypothesize how the current information management systems would contribute to the success of this plan 6 5 Critical Elements Success: Processes Success: Communication Articulation of Response Exemplary (100%) Meets “Proficient” criteria and provides nuanced insight into the organizational processes that will help the plan be successful Meets “Proficient” criteria and provides keen insight into how communication will help team members commit to the performance improvement plan Proficient (85%) Accurately describes the organizational processes that will help the plan be successful Needs Improvement (55%) Describes what organizational processes will help the plan be successful but description is inaccurate Not Evident (0%) Does not describe what organizational processes will help the plan be successful Value 4.5 Comprehensively explains how the plan will be communicated among departments and analyzes how that communication will help team members commit to the performance improvement plan Does not explain how the plan will be communicated among departments or analyze how that communication will help team members commit to the performance improvement plan 6 Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy-toread format Submission has no major errors related to citations, grammar, spelling, syntax, or organization Explains how the plan will be communicated among departments and analyzes how that communication will help team members commit to the performance improvement plan but patterns are not interdepartmental or analysis is cursory Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas 10 Total 100% 6 1 IHP 430 Milestone One Denise Vazquez Southern New Hampshire University 2 I. What is the Organizational Problem? A. Provide Medical errors are a public health care concern because every patient is vulnerable to their incidence and prevalence. In New Vale Clinic, physicians have been covering up errors that occur in medicine prescription, administration, and healthcare complications resulting from such errors. This goes against the report by the Agency for Healthcare Research and Quality on error prevention and quality improvement in healthcare (Rodziewicz et al, 2022). Medical error is a quality indicator, and failure to report cases of medical error is among the root causes of preventable cases of health complications due to wrong prescriptions and medication. B. State Leadership dynamics in the organization are a contributing factor to medication errors. Teams perceive the impact of leadership as a determining factor in their success in delivering quality care. When leadership dynamics are factored in, tension, frustration, and burnout become negative mitigating elements that lead to poor patient care delivery, characterized by several medical errors in the institution (Roberts, 2020). II. Evidence-Based Support A. Errors that occur either do or do not harm patients. Medical errors are the third leading cause of death in the United States following heart disease and cancer. A study by Johns Hopkins indicated that almost 250,000 Americans lose their lives 3 yearly because of a medical error. This is a crude approximation because of the wide range of medical errors that can occur. B. Prevention measures have been implemented in the past to address medical errors. These measures took a significant turn after the publication of the Institute of Medicine’s (IOM) report To Err Is Human: Building a Safer Health System (Ackley et al., 2019). Guidelines on how to avoid medical errors by AHRQ, and bar code readers to promote correct medication have been used in the past to reduce the incidence and prevalence of medical errors (Sorrell, 2017). C. Agency for Healthcare Research and Quality, AHRQ has been at the forefront of pushing quality initiatives, including sponsoring hundreds of patient safety research and implementation projects to prevent and reduce medical errors (Rodziewicz et al, 2022). 4 References Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing diagnosis handbook E-book: An evidence-based guide to planning care. Elsevier Health Sciences. Roberts, R. (2020). How Leadership Dynamics in Health Care Can Contribute to Medical Errors. Ohiostate.pressbooks.pub. Retrieved 11 September 2022, from https://ohiostate.pressbooks.pub/pubhhmp6615/chapter/how-leadership-dynamics-inhealth-care-can-contribute-to-medical-errors/. Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). Medical error reduction and prevention. In StatPearls [Internet]. StatPearls Publishing. IHP 430 Milestone Two Denise Vazquez Southern New Hampshire University Performance: Propose an Initiative First, teach on-duty physicians and nurses to reduce medical errors. Then-posted health staff will be separated into two groups and taught in hour-long interactive sessions, two in consecutive weeks. Using multimedia aids, they will learn pharmacological characteristics, doses, suitable preparations, intervals, and routes of administration of numerous newborn medicines. During training, they will get a typical medication list drawn from pharmacology textbooks. This will be presented at physicians’ and nurses’ workstations for medicine prescription and administration. The second strategy is to emphasize accountability. Physicians will sign prescriptions and nurses monitoring sheets. The QI team will double-check medications weekly following morning rounds using the same checklist. The initial challenge will be convincing residents and nursing staff to sign fully. Performance: Discuss Data Determinants of Success This program will enhance statistics like an organization’s annual money loss. When a claim is lacking information or the coding is erroneous, the organization loses money, which is bad for its success. If we look at the number of medical mistakes that occur each year and how much they cost organizations like Medicare, we can see the economic effects of medical errors on organization performance (Council For Medicare Integrity, 2018). The question; How will medical mistakes reduce after 3 months of software implementation? will inform us how successful the effort is and whether any adjustments are needed to make it work. This investigation’s results may be incorporated into the software to help hospitals reduce medical errors. Another data determinant is comparing before and after my initiative’s implementation. Thus, the outcomes and data may be more accurate. Implementation: Describe Interdepartmental Communication Channels A complete staff meeting is one technique to explain my idea to the team. The medical/coding section fills and sends out claims, but everything is a collaborative effort. If a patient enters the institution with erroneous or missing information, someone at the front desk committed a mistake that was unnoticed by other departments. Implementation: Describe the Manner of Data Interpretation I’ll use a bar graph to compare data before and after implementing my project. Since I’m comparing two items over a year, a bar graph is preferable. “Bar graphs compare groupings or follow changes over time. Bar graphs are ideal for measuring major changes over time (National Center for Education Statistics, n.d.). secondly, line graph will be used to show the annual loss of money and the reduction in medical mistakes after 3 months of initiative execution. Line graphs show short- and long-term changes. Line graphs are preferable for these determinants since the change is over a shorter time frame. Implementation: Effects of Initiative on Patient Care Outcomes My effort will improve patient treatment. Patients are happier with services as medical mistakes are declining. Medical mistakes may affect how patients feel about the hospital, which is bad since they aren’t happy with the services. Front-office concerns like medical and scheduling may affect how patients see medical interactions and rate them online. Providers should take note (Bryant, 2018). Non-insured individuals must pay out of pocket for treatments, therefore medical mistakes might cost them hundreds of dollars to resolve. Implementation: Effect of Quality Initiatives on Culture of Safety My idea will assist the organization’s safety culture by increasing patient care. Since medical errors have been reduced, professionals are more cautious about patients and prioritize them more since they no longer need to worry about making mistakes. This helped the institution boost patient satisfaction, which is positive. In a medical institution, one department’s dysfunction might affect the whole complex. This program will change things in a favorable direction, which is good for a facility. References Bryant, M. (2018, October 10). Patient satisfaction is up, but billing woes can hurt online reviews, survey shows. Healthcare Dive. https://www.healthcaredive.com/news/patientsatisfaction-is-up-but-billing-woes-canhurt-online-reviews-surve/539300/ Council For Medicare Integrity. (2018). Error Rate Drops, but Medicare Still Lost $31.6 Billion to Preventable Billing Errors in FY2018 | Council for Medicare Integrity. Medicareintegrity.Org. http://medicareintegrity.org/error-rate-drops-but-medicarestilllost-31-6-billion-to-preventable-billing-errors-in-fy2018/ National Center for Education Statistics. (n.d.). How Do I Choose Which Type of Graph to Use? – NCES Kids’ Zone. Nces.Ed.Gov. Retrieved 2020, from https://nces.ed.gov/nceskids/help/user_guide/graph/whentouse.asp 1 Success of the Performance Improvement Plan Denise Vazquez Southern New Hampshire University 2 The success of the Performance Improvement Plan Financial Preventable medical errors cost healthcare organizations a lot of money in terms of capitated payment arrangements. That’s because errors may increase the total cost of care so that it ultimately exceeds the fixed payment the organization will receive (Ahsani-Estahbanati et al., 2021). Additionally, for value-based care, failure to meet some quality expectations leads to compensated care needs (Ahsani-Estahbanati et al., 2021). With the proposed initiative to eliminate the onset and prevalence of medical errors. As a result, the expectation is that the cost associated with medical errors will reduce significantly. Information Management Systems Patient safety is a primary concern for all healthcare organizations. As part of achieving that goal, health information management systems are used to collect and analyze data on safe patient care delivery progress to facilitate information-based quality improvement metrics (Hutton et al., 2017). In the same way, the information management systems will be used to collect data on previous initiatives on preventing medical errors and compare them with other organizations to determine the chances of achieving the goal of the current initiative. Current Organizational Processes The organization is guided by the mission to uphold patient safety through the provision of resources. Resource availability is critical in determining the success rate of key initiatives. Nurses have access to patient information and can request the resources they need to identify atrisk patients and the strategies they can implement at the individual or organizational level to deliver safe care. 3 Communication of the Plan The teams will be notified through memos and the organization’s official communication platform. Most healthcare organizations still rely on memos to pass out key messages for official purposes. Apart from that, messages will be communicated through the company’s email address to reach out to those unable to access the memos. In other cases, short messages will be sent to specific teams through WhatsApp and other compatible media. 4 References Ahsani-Estahbanati, E., Doshmangir, L., Najafi, B., Akbari Sari, A., & Sergeevich Gordeev, V. (2021). Incidence rate and financial burden of medical errors and policy interventions to address them: a multi-method study protocol. Health Services and Outcomes Research Methodology, 22(2), 244-252. https://doi.org/10.1007/s10742-021-00261-9 Hutton, K., Ding, Q., & Wellman, G. (2017). The Effects of Bar-coding Technology on Medication Errors: A Systematic Literature Review. Journal Of Patient Safety, 17(3), e192-e206. https://doi.org/10.1097/pts.0000000000000366
