Initial Report for Shelbyville Medical Center Improvement Project

Initial Report for Shelbyville Medical Center Improvement Project 

This comprehensive report aims to analyze the areas of patient dissatisfaction identified in the Voice of the Customer (VOC) survey at Shelbyville Medical Center (SMC) and provide detailed recommendations for improvement. As a Level 1 trauma center, SMC faces significant pressure to deliver high-quality patient care. This report follows the Define and Measure phases of the DMAIC (Define, Measure, Analyze, Improve, Control) framework, focusing on understanding the root causes of dissatisfaction, proposing actionable steps for improvement, and providing a structured project plan.

The report will analyze three key areas of patient satisfaction that need immediate attention, describe the current patient care process at SMC through a process flowchart, evaluate the expected costs and benefits of moving forward with an improvement project, and propose a project charter. Additionally, the SIPOC (Suppliers, Inputs, Processes, Outputs, Customers) process diagram is provided to map out the emergency care process. This report also highlights the role of SIPOC and process flow documentation in informing the improvement project.

1. Using the chart below, identify the areas in patient satisfaction from the VOC report that should be targeted for improvement.
2. Explain why these areas should be targeted for improvement.
3. Discuss possible sources of process or performance deficiencies potentially contributing to negative patient perceptions.

Voice of the Customer
Areas (at least three) in VOC that should be targeted for improvement	1. Doctor-Patient Communication   2. Pain Management   3. Clarity of Post-Discharge Information
Rationale for selecting each of these areas	1. Doctor-Patient Communication Rationale: The VOC survey indicates that only 76% of patients reported that their doctors “Always” communicated well, compared to the national average of 82%. This gap highlights a clear opportunity to enhance communication between doctors and patients. Effective communication is integral to building trust, improving patient satisfaction, and ensuring that patients understand their treatment plans, which can lead to better health outcomes. Research consistently shows that effective communication results in greater patient compliance, higher satisfaction, and a more positive perception of the healthcare facility (Ha & Longnecker, 2010). Potential Impact: Improving doctor-patient communication will address patient frustrations and foster a better therapeutic relationship. Clear communication can reduce misunderstandings, clarify treatment plans, and empower patients to actively participate in their care. 2. Pain Management Rationale: Although 72% of patients reported that their pain was “Always” well controlled, this score is only marginally better than the national average of 71%. Pain management is one of the most significant aspects of patient care, particularly in trauma centers where patients experience high levels of pain. Any deficiency in pain management not only affects patient comfort but also leads to negative perceptions of care quality. Inadequate pain control can result in dissatisfaction, increased anxiety, and a perception of inadequate care (Ahmadi et al., 2016). Potential Impact: Improving pain management practices will lead to greater patient comfort, reduce the likelihood of negative experiences, and improve overall satisfaction with the care provided at SMC. By addressing the gap in pain control, SMC can enhance its reputation as a trauma center that prioritizes patient well-being. 3. Clarity of Post-Discharge Information Rationale: The VOC survey reveals that only 45% of patients “Strongly Agree” they understood their care when they left the hospital, compared to the national average of 51%. This statistic suggests that many patients struggle with post-discharge instructions, which can lead to confusion, complications, or even readmissions. Clear, concise, and personalized discharge instructions are crucial for ensuring patients understand their care plan and recovery instructions, ultimately improving recovery outcomes and reducing the risk of readmission (Jack et al., 2009). Potential Impact: Ensuring patients comprehend their discharge instructions will lower the likelihood of readmissions, improve patient satisfaction, and enhance the quality of care. This change will allow SMC to better meet patient expectations and provide care beyond the hospitalization period.
Discussion of deficiencies	Doctor-Patient Communication: One of the most likely deficiencies for poor communication outcomes is the absence of defined communication frameworks. A physician may insufficiently allocate their time to explain a diagnosis, treatment, and its anticipated result. Moreover, different cultures and languages may make social interactions difficult. In addition, a lack of proper training for an overloaded physician on adequate communication may lead to inaccurate assumptions. Pain Management: Insufficient attention as the patient comes through the admission desk or after a procedure could be driving the gap in pain management. Non-adoption of pain assessment standards by nurses and doctors may apply. Also, especially in triage patients, pain medications have been found to be poorly administered. The longer patients have to wait for pain relief, the more dissatisfaction there is, and in trauma care, it is often the most pressing problem. Post-Discharge Information: Post-discharge informational gaps are likely a direct result of inconsistency in the discharge process. Discharge instructions are often generic and do not cater to individual patient needs, nor do patients receive adequate follow-up care to confirm understanding. Furthermore, patients do not have the opportunity to ask questions, which leads to uncertainty regarding medication instructions, follow-up appointments, or home care instructions.

 

1. Process Flowchart. Construct a current-state process flowchart that starts with a patient registering at triage and ends with the patient receiving care from the attending physician.

┌──     ┌───────────────────────┐         ┌─────────┐           ┌───────────────┐            ┌───────────────────────┐

│    Start       │────▶│ Registration at Triage │────▶│ Initial Assessment by              │

└────────┘            └────────────────┘            │       Nurse                              │

└───────────────────────┘

│

▼

┌───────────────────────┐

│ Vital Signs & Symptoms             │

│     Documentation                    │

└───────────────────────┘

│

▼

┌───────────────────────┐

│ Doctor Assessment &               │

│     Examination                        │

└───────────────────────┘

│

▼

┌───────────────────────┐

│ Pain Management                    │

│     Evaluation                           │

└───────────────────────┘

│

▼

┌───────────────────────┐

│ Care Plan Creation                   │

└───────────────────────┘

│

▼

┌───────────────────────┐

│ Patient Discharge &                 │

│      Education                           │

└───────────────────────┘

│

▼

┌───────────────────────┐

│ Follow-Up Plan                        │

│     (If Needed)                         │

└───────────────────────┘

│

▼

┌───────────────┐

│     End                    │

└───────────────┘

 

SIPOC Process. Complete the “Suppliers, Inputs, Process, Outputs, and Customers (SIPOC) Process” diagram below.

Costs and Benefits. Analyze the expected costs and benefits if Shelbyville Medical Center (SMC) chose to do the following:

1. Keep things the same and not complete an improvement project
2. Move forward with the improvement project

	Costs	Benefits
Keep things the same and not complete improvement project	–      Continued low patient satisfaction ratings and negative feedback. –      Increased risk of patient dissatisfaction, leading to potential lawsuits or negative reviews. –      Possible decrease in patient retention and hospital ratings. –      Legal and financial implications due to readmissions or complaints.	–      No financial cost of implementing new processes or staff training. –      No immediate operational disruption.
Move forward with improvement project	–      Initial resource allocation for process improvements and training. –      Time and effort required to re-design processes and implement new protocols. –      Potential disruption in current operations during the transition phase. –      – Possible initial financial investment in technology and training.	–      Improved patient communication, leading to higher satisfaction. –      Better pain management, resulting in enhanced patient comfort and satisfaction. –      Reduced risk of readmissions, as patients will better understand their discharge instructions. –      Enhanced hospital reputation, leading to higher ratings and patient retention.

Project Charter. Complete the following Project Charter:

Project Name	Improving Patient Satisfaction at Shelbyville Medical Center
Project Context	This project aims to address critical areas of patient dissatisfaction identified through the VOC survey, particularly in doctor-patient communication, pain management, and post-discharge clarity. The project will follow the DMAIC framework, with a focus on enhancing communication and care delivery to improve overall patient satisfaction.
Need for the Project	As a Level 1 trauma center, SMC must ensure high-quality care and patient satisfaction. The identified areas of improvement are crucial for maintaining the hospital’s reputation and ensuring compliance with healthcare quality standards.
Opportunities for Improvement	Three opportunities for improvement Doctor Communication Pain Management Post-Discharge Information Clarity
Improving Operations	By optimizing workflows (e.g., triage protocols, staff training, and resource allocation), SMC can reduce bottlenecks, improve patient flow, and foster a culture of continuous improvement.
Quality Metrics	1. Doctor Communication: Percentage of patients who report effective communication (goal: 82% or higher). 2. Pain Management: Percentage of patients satisfied with pain relief (goal: 90% satisfaction). 3. Post-Discharge Information: Percentage of patients who fully understand discharge instructions (goal: 60% or higher).
Objectives	Enhance doctor-patient communication to meet or exceed the national average. Improve pain management satisfaction by 20%. Increase patient understanding of post-discharge instructions to at least 60%.
Projected Benefits	Enhanced patient satisfaction and retention. Improved hospital reputation and quality ratings. Reduced readmissions due to better post-discharge understanding.
Project Scope	Focus on improving communication, pain management, and discharge education in the emergency and trauma care departments.
Timeline	6 months for full implementation, with monthly progress reviews.
Departments or Services Involved in the Project	Emergency Care, Nursing, Pain Management, and Patient Education.
Participants from Departments or Services Involved in the Project	Dr. Jane Doe – Process Expert (Doctor) Nurse John Smith – Subject Matter Expert (Nursing)
Roles of the Participants from Departments or Services Involved in the Project	Dr. Jane Doe: Oversee the implementation of improved communication practices for doctors and staff. Nurse John Smith: Lead the development and delivery of new discharge education protocols for nursing staff.

 Explanation of SIPOC and Current-State Process Flow Documents.

How does the SIPOC and current-state process flow documents inform the current improvement project?

The SIPOC diagram and process flowchart serve as critical tools for identifying inefficiencies and areas for improvement in the emergency care process. These documents help the CQI team visualize the flow of information and services from the moment a patient enters the hospital to the point of discharge. By mapping out the process and identifying key stakeholders (suppliers, inputs, processes, outputs, and customers), the team can target specific stages for intervention. The flowchart, in particular, highlights potential bottlenecks or areas where communication breakdowns may occur, such as during the patient assessment or discharge process.

APA Sources:

Ahmadi, A., Bazargan-Hejazi, S., Zadie, Z. H., Euasobhon, P., Ketumarn, P., Karbasfrushan, A., Amini-Saman, J., & Mohammadi, R. (2016). Pain management in trauma: A review study. Journal of Injury and Violence Research, 8(2). https://doi.org/10.5249/jivr.v8i2.707

Jack, B. W., Chetty, V. K., Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E., … & Culpepper, L. (2009). A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Annals of Internal Medicine, 150(3), 178–187. https://doi.org/10.7326/0003-4819-150-3-200902030-00007

Ha, J. F., & Longnecker, N. (2010). Doctor-patient communication: A review. Ochsner journal, 10(1), 38-43. https://www.ochsnerjournal.org/content/10/1/38

SIPOC Process

Supplier(s)	Input(s)	Process(es)	Output(s)	Customer(s)
List the supplier(s) in the emergency care process.	List the input(s) in the emergency care process.	List the key process(es) in emergency care.	List the output(s) in the emergency care process.	List the customer(s) in the emergency care process.
Nurses	Patient Information	Triage and Initial Assessment	Triage Assessment Results	Patients
Doctors	Patient History, Vital Signs	Diagnosis, Treatment Planning	Diagnosis and Treatment Plans	Patients
Laboratory	Diagnostic Test Results	Test Results Interpretation	Results Report	Doctors, Patients
Pharmacy	Prescriptions	Medication Preparation	Medications Administered	Patients, Doctors
Administrative	Patient Demographics, Insurance Info	Patient Admission and Discharge Processing	Admission/Discharge Summary	Patients, Insurance

 

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Initial Report for Shelbyville Medical Center Improvement Project

Introduction:
This initial report will help guide your understanding of tools used in the define and measure phases of the DMAIC model when undertaking a quality improvement project. The information and insights gained from completing the initial report will be used in Tasks 2 and 3. You must also create a process flowchart, perform a cost-benefit analysis, and complete a project charter as part of this task.

Scenario:
You are a healthcare administrator at Shelbyville Medical Center, a high-functioning level 1 trauma center. You and the organization’s continuous quality improvement (CQI) team are accountable for implementing an improvement project using the define, measure, analyze, improve, control (DMAIC) model. During the define and measure phases, Shelbyville’s CQI team brings a recent customer satisfaction report called the “Voice of the Customer” (VOC) survey to the organization’s attention. The report highlights several opportunities that must be addressed. In response to the survey results, the CQI team conducts interviews with staff members from various departments.
Your assignment is to identify processes that need to be improved in response to the VOC survey and define metrics to measure improvement over time.
Requirements
Your submission must represent your original work and understanding of the course material. Most performance assessment submissions are automatically scanned through the WGU similarity checker. Students are strongly encouraged to wait for the similarity report to generate after uploading their work and then review it to ensure Academic Authenticity guidelines are met before submitting the file for evaluation. See Understanding Similarity Reports for more information.

Grammarly Note:
Professional Communication will be automatically assessed through Grammarly for Education in most performance assessments before a student submits work for evaluation. Students are strongly encouraged to review the Grammarly for Education feedback prior to submitting work for evaluation, as the overall submission will not pass without this aspect passing. See Use Grammarly for Education Effectively for more information.

Microsoft Files Note:
Write your paper in Microsoft Word (.doc or .docx) unless another Microsoft product, or pdf, is specified in the task directions. Tasks may not be submitted as cloud links, such as links to Google Docs, Google Slides, OneDrive, etc.  All supporting documentation, such as screenshots and proof of experience, should be collected in a pdf file and submitted separately from the main file. For more information, please see Computer System and Technology Requirements.

You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.

Create an initial report in response to the VOC report found in the course. Complete the attached “Initial Report Template” by doing the following:

A. Identify the areas in patient satisfaction from the VOC report that should be targeted for improvement.

1. Explain why these areas should be targeted for improvement.

2. Discuss possible sources of process or performance deficiencies potentially contributing to negative patient perceptions.

B. Construct a current-state process flowchart that starts with a patient registering at triage and ends with the patient receiving care from the attending physician.

C. Complete the “Suppliers, Inputs, Process, Outputs, and Customers (SIPOC) Process” diagram in the attached “Initial Report Template.”

D. Analyze the expected costs and benefits if Shelbyville Medical Center chose to do the following:

1. keep things the same and not complete an improvement project

2. move forward with the improvement project

E. Complete a project charter that includes the following:

1. the name of the project

2. the context of the project

3. an explanation of the need for the project

4. three opportunities for improvement relevant to the current situation

a. an explanation of how this project will improve healthcare operations at Shelbyville Medical Center

5. identify the quality metrics that should be used to indicate improvement in each of the identified areas of patient satisfaction concerns from prompt A1

6. the project’s objectives

7. a discussion of the projected benefits of the project

8. the project’s scope

9. the project timeline

10. an identification of the departments or services involved in the project

a. an identification of two of the participants from the departments or services involved in the project identified in part D10

i. a description of the two participants’ roles as part of the improvement team

Note: Examples of roles include subject matter expert, process expert, or stakeholder.

F. Explain how the SIPOC and current-state process flow documents inform the improvement project.

G. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.

H. Demonstrate professional communication in the content and presentation of your submission.