NURS FPX 6222 Assessment 4 Outcome Measures, Issues, and Opportunities Presentation

Student Name

NURS-FPX6222

Capella University

Professor Name

Submission Date

Outcome Measures, Issues, and Opportunities Presentation

Hi, I am _______. For this presentation, I will be talking about outcome measures, issues, and opportunities.

Slide 1

Key Quality and Safety Outcomes

Communication between health professionals is a key element in patient safety and in the good performance of the health organization. Communication failure, particularly during handoff, is one of the common causes of errors and is a problem that occurs. In healthcare organizations, there are certain indicators used to assess the overall performance, which include the number of times there are medication errors, patient satisfaction, rates of hospital admission, and sentinel events. Lack of effective communication, especially when there is a transition in care, is due to inconsistencies. During transition in care, a structured communication tool, for example, situation, background, assessment, and recommendation (SBAR), can begin to be used in the facilitation of communication between clinicians. Communication will not only lead to better patient care results but also meet the patient satisfaction and trust needs and accreditation standards.

Slide 2

Systemic Problem in the Organization

The most significant communication issue that is likely to occur in this organisation is a lack of communication when patients are moved from one health worker to another in relation to inter-organisational transfers. Failure to communicate may cause loss of important patient information about their fall risk, compromising patients’ health. In the common scenario of doctors, nurses, and employees working in different departments, several factors—including staff shortages, stress before transferring, lack of communication training among employees, and the institutionalisation of communication among employees—will lead to the less frequent use of the structured SBAR system by the nurses. This will make it difficult to work together with other professionals and to be able to share patient information. This results in higher rates of treatment errors, patient readmissions, patient dissatisfaction, and sentinel events. So, if not, employee burnout and dismal morale will have a negative impact on organisational results.

Slide 3

Analysis of Organizational Functions, Processes, and Behaviors

Top-performing health care systems have a structure, roles, processes, and behaviors that continually strive to increase the safety of care and improve health care outcomes. Communication within the class will be structured and will follow the approach of ‘Structured Communication ‘, which will ensure consistency, clarity, and completeness in communication with all patients receiving the same treatment after the patient. There is rational analysis (by an interprofessional team of leadership and front-line staff who know about the case or process being analysed) that is consistent, and they explain findings. If the case is not applicable to the rational analysis, then there is information from relevant literature. These kinds of organisations will likely have leaders who will be transformational leaders. Transformational leaders are clear, involve everyone in decision-making, and foster a work culture in which employees can feel safe. These attitudes can contribute to a positive safety culture, unity, and honesty.

Slide 4

Knowledge Gaps and Areas of Uncertainty

There’s some good in this organization as it is, but there are a lot of questions and some unclear issues with the structure of the organization. Firstly, in the organisation, the process and training of transition is not standardised, as seen in the creation of such risks. In addition, it’s unclear if the current handoffs are of high quality and effective. During this time, such declarations might be rather difficult due to a limited amount of data relating to this topic. Many studies have been conducted on organisational culture and hierarchy as factors affecting good communication and escalation of concerns relating to patient safety incidents. To create a more sustainable way of improving workflow, more in-depth research is needed to understand the reasons for the ineffectiveness of workflow and the meaning and perception given to the “communication” between disciplines by the workers.

Slide 5

Impact of Organizational Functions, Processes, and Behaviors

The outcome indicators will be influenced by organizational activities, operations, and behaviors, as this will impact the quality and safety of care delivery. Structured and standardized communication processes like SBAR communication make a difference, reduce medication errors, improve patient satisfaction, and reduce readmissions. Medical safety and quality treatment in a medical setting is also reliant on the number of nurses to patients. Furthermore, an interdisciplinary approach and leadership behaviour lead to effective coordination and no delay in providing care. These discrepancies, caused by fragmented systems, communication hierarchy, and a lack of training, cannot ensure consistency of practice and avoid poor patient safety practices.

Slide 6

Assumptions Underlying the Determination

The underlying logic behind these choices is that standardising processes for communicating as part of what patient safety means, and standardising the processes that provide care, will have a positive impact on the quality of the communication that is part of providing care. The first assumption is that there is a commitment from the leaders to put into action these intervention strategies. A sufficient number of staff members and suitable training facilities will be provided to ensure the implementation of improvement actions. Further, Singh recommends that if an intervention is successful, it would require a joint effort in dealing with cases, a good communication system, and the involvement of other professions in diagnosis. Lastly, the reliability of the outcome measures would be as good as that of clinicians and improved communication.

Slide 7

Quality and Safety Outcomes and Associated Measures

Some health care indicators that can be used as measures of quality and safety within an organization could be the number of medication errors, the presence of hospital-acquired infections, patient satisfaction, hospital falls, sentinel events, and hospital readmission rates. These can be recorded in incident reporting, electronic health records (EHRs), patient satisfaction surveys, audits, and dashboards. In addition, there are fewer chances for errors to occur when care is coordinated across transitions because the care would be continuous, information would be accurately transferred, and the strategies for care would all be relevant to the patient’s needs and preferences. Communication – following the SBAR model and documentation accuracy and completeness are measures of the effectiveness of care transitions. Staff indicators such as turnover, staff burnout, and attendance at communication training programs are other indicators for assessment.

Slide 8

Evaluation of Data Quality

The accuracy of reporting, documentation of the data, and safety culture will have an impact on the quality of data that is collected. While there are several different ways of implementing EHR, assessing the effectiveness of EHR is a relatively complex process, involving technical, organizational, and human factors. EHRs do contribute to more accurate data, but there is a potential for underreporting and/or inconsistent data. Moreover, there is hardly anybody who flags up situations when people did not communicate effectively, or when there was a near miss, as a consequence of fear, or psychological safety issues causing an incomplete set of data. Finally, the measurement of the communication results may vary across organizations—in the focus and definition of these specific communication-related measures. So, the use of measures by hospitals gives information regarding their safety and quality performance, but one has to be aware of the potential for their interpretation to be biased.

Slide 9

Performance Issues and Opportunities in Organizational Functions and Processes

The primary issues in lack of consistency are the communication procedures followed, the patient transfer, as well as the handoff of the patient. If not uniformly used across the entire organization, standardised SBAR will lead to different styles of using the communication tool to deliver clinical information between departments and shifts, leading to issues with medication errors, missed medication, or incomplete documentation. Additionally, there are other problems that affect the performance of an organization, such as poor communication training throughout the organization followed by a rush to transition between shifts, which negatively affects patient safety, and a lack of staff. Many studies have shown that the nurse-to-patient ratio has been seen to impact patient mortality, infections, errors, readmissions, and patient satisfaction. But there are opportunities for organizations to improve their performance by using standardized communications, fixing SBAR into the EHR, and real-time quality dashboards. Competency-based training programmes and accountability will help further enhance performance.

Slide 10

Organizational Processes and Care Delivery Gaps

There was some variation in care that was provided, especially when patients were transferred into or out of care, between the levels of care, and at the exit (discharge) point from the hospitals. Often the cause of falls is attributed to system issues, lack of communication, and lack of situational awareness. This causes patients to lose continuity of medical care as well as increases the chance for patients to suffer med errors, hospital re-entry, and more. This impacts continuity of care for patients, which leads to other negative outcomes, including medication errors, readmission, and sentinel events. Besides the points mentioned above, there are also some point challenges in documentation and non-coordination with other departments within the department. Some solutions around leadership involve identifying staffing needs, optimizing workflow, determining how to make the use of EHRs more efficient, and making all things more effective in terms of handoffs. But also, better multi-disciplinary working and ready access to patient data via health information technology may help to improve the care processes.

Slide 11

Organizational Behaviors and Safety Culture Opportunities

Organizations’ behaviors can have a great impact on the communication process in the health care environment. The fear of possible legal consequences, fear of criticism from peers, negative attitude towards mistake reporting, insufficient time, and complex process of mistake reporting are some of the possible reasons for underreporting. Besides, factors such as psychological safety may be another reason for the failure of effective communication: an employee may feel afraid of being punished/criticised for the mistakes that he/she may have committed during the process of reporting. There are factors that interfere with efficient teamwork and coordination: Limited and unreliable communication tools, resistance to change. A myriad of possibilities exist for laying the foundation for a robust safety culture, such as transformational leadership, psychological safety, and open communication at various levels. The consistent use of Joint Commission procedures will also make it easier to not only avoid meaningless humongous failures but also to treat each failure as a learning moment and a moment of improvement. With the establishment of a non-punitive reporting and learning culture, there is also an increase in the reliability of the care delivery process for patients.

Slide 12                                                                           

Knowledge Gaps and Areas of Uncertainty

However, there are certain elements about uncertainty and gaps in knowledge that cannot be overcome in order to gain a full understanding of the performance issues and how these issues relate to communication within the organisation. First, there is a lack of knowledge about staff members’ degree of readiness and willingness to implement all communications effectively. Secondly, it seems there is some variation in the current handover processes due to the small number of audits that are carried out by the organisation, with no standardisation of documentation processes. To reduce nursing handover errors, a holistic approach including communication processes during the handover, environment, systems in place, and nurses’ abilities is required. Furthermore, the relationship between organizational culture, management, psychological safety, and communication and error reporting processes is not well understood. Whatever may have been attempted before to fill in gaps with quality programs is yet to be seen whether they were successful or not. There is a need for further research to assess the effectiveness of the workflow, the views of staff members, and problems with interprofessional working.

Slide 13

Change Strategy for Measuring Patient Care and Sharing Knowledge

For measuring the outcomes of care consistently within an organisation and for knowledge sharing, a systematic approach towards change has to be put in place. One of the important models of change in the organization is the change management model of Kurt Lewin because it is a change that is managed in a certain way and organized change. This starts with assessing the communication risks to safety, raising the awareness of the staff, and outcomes, which include medication errors, readmissions, and sentinel events. Secondly, a consistent approach to communication is adopted (e.g., SBAR and staff training). Real-time monitoring systems that hold people accountable are used to measure performance. Finally, there are the processes of continuous feedback (which provides opportunities for sharing knowledge) and leadership support (which provides continuity to the successes) in the area of measuring patient care and measuring organisational learning.

Slide 14

Strategy for Measuring Patient Care and Sharing Knowledge

The change management model developed by Lewin serves as a framework for a structured improvement process, and can be used to measure patient care outcomes and to spread knowledge of effective patient care. The sharing of information with staff in the unfreeze step includes communication errors related to medicines, re-admission, and sentinel events. In training, communication skills (SBAR and others) are developed in all departments, and competency-based training is developed through the EHR system at the stage of change. In this phase, new processes get adopted, new behaviors are developed, and the beginning steps of the organization can see the fruit of their labor. During the refreezing stage, the new practices are incorporated into the organisation’s policy, and the audit, performance feedback, and retest of the educational activities help to reinforce the new practices.

Slide 15

Opportunities for Interprofessional Collaboration

A big part of the health workforce is multidisciplinary, and this is very crucial in terms of providing proper communication, safety, and coordination in service delivery. Interdisciplinary rounds are one way in which this aspect could be achieved. In the present case, various health care providers (including nurses, doctors, and pharmacists) discuss various aspects of the patient’s care plan and the results it has achieved. The different team members had been working together since achieving effective, efficient communication and sharing vital patient information, ensuring that they would provide quality patient care results. Interprofessional education may be provided through simulation-based education, training of more than one health care professional in the effective use of the SBAR communication model in various situations. By using the Quality Dashboard Live, each discipline will be able to monitor their performance and make planned interventions. This will foster the culture of respect, accountability, and trust within the health group, which will lead to improved care, care coordination, and an improved culture of safety within the health organisation.

Slide 16

Conclusion

Poor communication between healthcare organisations during handoffs is a major issue that impacts patient safety, health outcomes, and healthcare efficiency. The practice area issues are related to the lack of consistent communication practices, lack of standardized communication practices, and organizational issues, which increase patients’ vulnerability to medication errors, delays in care, and readmission to hospital. Good practice around SBAR communication and increased inter-professional working and Lewin’s model of change help to improve this. Standardisation of measuring patients’ outcomes and spread of knowledge will improve change. Improvement in both areas will positively impact patients’ results, the efficiency of the employees, as well as long-term organizational performance.