NURS FPX 6612 Assessment 2 Quality Improvement Proposal

NURS FPX 6612 Assessment 2 Quality Improvement Proposal

Data Analysis and Quality Improvement Initiative Proposal

Understanding how data is collected, analyzed, reviewed, and monitored for quality improvements (QI) is essential for a successful QI initial proposal plan. Getting nurses to accept the need for QI initiatives ensures that initiatives are being followed to improve compliance with healthcare policies and improve the quality of care the patients receive.

Analyzing Vila Health Data

Data is an objective view of studying how information changes. It provides a direct comparison to be made over time, allowing for the determination of improvement or worsening of patient care (National Institute for Children’s Health Quality, 2022). Looking at the value of the numbers compared to over a year in the case of Vila Health’s hospice and home health adverse event data allows for the comparison of which areas are showing improvement and which areas require additional initiatives to promote better patient care. After implementing quality improvement (QI) initiatives, the data will then be reevaluated to determine if the initiatives were effective.

The data were analyzed at Vila Health’s hospice and home health adverse event data for 2014-2015. It is unclear if the values reported in the data are each patient or percentages and would need to be clarified for complete information. For this analysis, it will be assumed that it is per patient. There are four data sections available for analysis, including the length of stay (LOS) of less than seven days, in-patient unit (IPU) admission, pain level 7-10 longer than 24 hours, and unresolved pain over 24 hours. LOS of less than seven days decreased by four from 2014 (50) to 2015 (46). IPU admission dropped from 47 in 2014 to 27 in 2015. In 2014, 13 patients reported pain between 7-10 over seven days, which increased to 17 in 2015. Finally, the number of patients who had inadequate pain relief lasting longer than seven days increased from 13 (2014) to 22 (2015). The primary analysis showed that the pain management for patients in hospice care was not adequately managed and could use additional quality improvement. Areas of concern that are critical to evaluate outcomes include pain levels reported 7-10 longer than 24 hours and inadequate pain relief after 24 hours because both of the pain data showed an increase from 2014 to 2015.

The organization could separate the measurements as near misses and events that caused harm. The data states that the data includes both. However, dividing the numbers of what caused patients harm could highlight which areas require more interventions to prevent harm to the patients in the care of Vila Health. Also, missing data includes how healthcare providers are assessing pain and what the policy is for Vila Health on patients reporting pain. Additionally, reviewing the demographic of the patients who report elevated pain could be helpful. Some cultures view pain as a weakness and under-report pain. Women and men report pain differently, and different generations view pain differently (Chi et al., 2018). To continue to analyze initiatives’ success and patient outcomes, Vila Health should continue to monitor all adverse events and near misses to promote continued growth and improvement.

NURS FPX 6612 Assessment 2 Quality Improvement Proposal

Interdisciplinary Team Impute

A national quality improvement initiative set by the Agency for Healthcare Research and Quality (n.d.) states that patients in hospice care receive adequate assistance with pain, sadness, breathing, and constipation from the hospice team. The national improvement remains unchanged, with a -0.3% change (Agency for Healthcare Research and Quality, n.d.). The quality improvement set on hospice care patients receiving adequate assistance with pain allows the patient to be comfortable during their time in hospice. Additionally, addressing pain in a patient allows the patient to participate in their daily activities. Remaining active in the care provides the patient with confidence and promotes movement, increasing their quality of life.

Another national quality improvement initiative described by the Agency for Healthcare Research and Quality (n.d.) discussing pain states that pain was educated on within two months of care with home healthcare providers. Palliative care has adapted to using patient-centered adapted quality improvements to get the patient to the pain management they want and addressing the patient’s feelings, being heard and understanding their pain management (National Coalition for Hospice and Palliative Care, 2019).

A proposal to improve patients’ pain management includes implementing an interdisciplinary team approach that consists of the patient, the nurse, caregivers, and family to reach the benchmark. To start the proposal, all team members must be able to open a line of communication among all members of the interdisciplinary team.

In-home care with pediatrics who are mechanically ventilated, movement dependent, and have tracheostomies, the use of non-verbal pain assessments are vital to determine pain. The pain assessment tools are adapted and reevaluated depending on the patient to obtain accurate pain signs and symptoms. QI initiatives are not only created to develop better company outcomes but are designed for patient-specific pain assessment to ensure all healthcare members can measure pain the same way. For example, the patient mentioned that I primarily care for is unable to communicate except for facial expressions. No pain assessment currently in use allows for this regular assessment. The non-verbal pain assessment requires evaluating the patient’s muscle tension and activity, which will always be zero in this patient. The critical care pain observation tool requires ventilation compliance evaluation (which is not assessed because of chronic respiratory failure due to ventilator dependency), body movement, and muscle tension (the patient has no control of muscles from the neck down) (Creek, 2019). Therefore, an internal quality improvement initiative that the nurses implemented was to create a pain scale specific to his assessment.

Previously, QI initiatives only focused on cancer pain management, relieving symptoms, and how to live a comfortable life. However, research has been adapting to ease end-of-life comfort in hospice care and in-home care. Some research has suggested eliminating the use of pain assessment charting due to its contribution to the opioid epidemic (Levy et al., 2018). The increase in opioid overuse has led many families and patients to be scared of using pain medication in-home care and palliative care, resulting in many patients suffering from unnecessary pain. However, insignificant pain management significantly causes the patient’s body to work harder, creates emotional distress in the patient, and decreases the patient’s quality of life (Lee et al., 2019). Misinformation that the nurses and health care providers must be ready to explain to their patients to improve knowledge in the patient’s treatment planning.

Target areas needed for improving the process and the outcome include assessment and evaluation. Pain is a subject report of potential or actual damage caused to tissue (Lee et al., 2019). The need to address this during hospice and in-home care is essential in ensuring the patient is comfortable in their home environment and can heal or live comfortably throughout their life. Improving the outcome by decreasing the reported pain to less than five within 24 hours increases the patient’s quality of life, enhances patient satisfaction with care, and increases the nurses’ satisfaction in their job (Boamah, 2018). However, challenges that may arise might be resistance from nursing staff to change their assessment or feeling as if the administration is blaming them for the increase in patients complaining of unresolved pain. Including nurses in the planning phase of solving the issues and implementing a proposal can drastically improve the nurses’ compliance and participation.

NURS FPX 6612 Assessment 2 Quality Improvement Proposal

Data Factored into Outcomes and Recommendations

Assessing the adverse events or near-miss data failure mainly focuses on the failure to treat pain in patients in-homecare and hospice care. Patients in hospice care often have terminal diseases and report high levels of pain, requiring control medications to be administered. Information needs to be gathered to be able to analyze the information (Toney-Butler & Thayer, 2020). Data collection is vital in ensuring all information is available to create a complete plan of care for the patient.

Once all the assessment information is gathered, the information can be reviewed to determine a diagnosis of the failures leading to the adverse event. The nurse looks for trends that are abnormal that need to be corrected. The abnormal trends could be heart rates, blood pressure, pain levels, or any other abnormal measurements that need addressing. Using Maslow’s Hierarchy of news is a great start to determining the highest level of needs to address (Toney-Butler & Thayer, 2020). For example, suppose nurses are assessing pain only during visits, but no additional assessment is being completed when a nurse is not present; then education on how medication use should be given to caregivers to relieve pain or education on how to request assistance from the nurse on call. Knowing where the issue lies greatly improves what is leading to the adverse event.

Once a trend or problem is identified, a plan can be created. Planning uses the nurse’s knowledge of the information provided and organizes them into areas that can be improved and are patient-specific. The nurse uses their knowledge of how the body works and plans steps on how to make the trends or abnormal measurements become normal again. The data is essential to be evaluated to determine the outcomes and recommendations. During the planning phase, the outcome is determined. The goal is patient-centered, time-specific, measurable, and realistic (Toney-Butler & Thayer, 2020).

Putting the plan into action, also known as the implementation stage, is the next step in using the nursing process to examine failures that can lead to adverse events (Toney-Butler & Thayer, 2020). All interventions created during the planning phase are used to reach the desired outcome making the patient return to their baseline.

Finally is evaluation. No plan is going to be perfect the first time through. After the plan is put in place, the plan should be reassessed for new or missed complications. These complications should then go through the entire process again (Toney-Butler & Thayer, 2020).

Safety and Quality Outcomes

Vila Health in-home care and hospice data show an increase in patients complaining of pain over seven on the pain scale for longer than 24 hours. More data is gathered by asking what the patient wants with their pain management. Asking how they rate their pain, what pain is acceptable, and how they would like to treat their pain is also an assessment tool for all team members to understand what the patient wants (National Coalition for Hospice and Palliative Care, 2019). The first step in the proposal sets up the groundwork for the patient to get what they want and need. Understanding what the patient needs to feel their pain is being addressed allows for better pain management.

The second step of the proposal includes addressing the patient’s feelings, ensuring the patient feels heard, and answers to questions are understood. The patient is asked how they are feeling about their pain management. Knowing how the patient feels gives a view into what the patient needs and what areas of concern still need addressing. Next, the patient is asked if they think they are being heard. Ensuring the patient feels they are being listened to ensures that the patient gets the care they want. Finally, the care team must provide the patients understanding of all aspects of their care (National Coalition for Hospice and Palliative Care, 2019). Another aspect of understanding the patient should understand how to rate their pain and an agreed-upon pain scale.

Education is an essential part of this step to ensure the patient, family, and caregivers understand the treatment plan. The education promotes compliance and provides an understanding of what will happen—teaching the patient and the family the importance of treating pain. Discuss the patient’s goal pain level and how they will reach that goal. What other techniques can be used when the pain level is increasing? What pain level would the patient like pain medication to give? If a patient is unresponsive, discuss the non-verbal signs of pain with the family and educate them on how to use the Nonverbal pain scale for nonverbal patients. Education will be given to patients and caregivers; however, there is a stigma that many will not be able to change to use pain medication to their fullest capability. The misinformation about opioid use in chronic pain and hospice care can lead to under-treatment of pain.

Additionally, due to the side effects of pain medication, some family members feel the use of high-dose opioids can lead to respiratory depression and, ultimately, death. They are improving the education of the family, caregivers, and patients to ensure proper pain reporting. Another area for improvement includes incorporating all healthcare team members in creating a pain management plan to decrease the patient’s pain, with a clear understanding of each member’s roles and the patient’s wishes. Educating the caretakers and allowing a collaborative pain management plan of treatment incorporates known research and data to ensure the patient is being cared for and pain is managed effectively for the child who cannot advocate for themself.

Once a pain treatment plan is created, the plan should be displayed in the patient’s room for easy referral. Having the plan ready and able for referral allows all caretakers, the patient, caretakers, and the patient to review and reevaluate the plan as needed, creating good communication for all interdisciplinary team members. Having the plan available additionally addresses any challenges that could be met if a family member disagrees with the amount of pain medication the patient is receiving or allows the patient to change their plan to reach their desired pain level.

The patient’s role is to understand how to communicate with their family, caregiver, nurse, and other providers when they are in pain and would like pain medication. The nurse’s role is to educate the patient and family on recognizing pain and how to treat the pain. Educate the patient and family on the side effects of the pain medication, tolerance, and addiction. Finally, the family’s role is to listen to the patient and view their pain as accurate and respect their decision on when they need pain medication. Explore their own beliefs, understand pain medication, and understand the need for pain medication to promote a comfortable quality of life until the patient terminates care. Explore the family’s views on what they want for their loved one during the consideration in hospice and compare with the patient’s wishes to ensure the patient’s wishes are being respected.

Keeping open lines of communication between all team members engages each member in knowing how each member of the team will participate in ensuring the patient is being cared for and comfortable. Also, ensuring all interprofessional team members understand their roles in the patient’s care plan keeps each member engaged in the care providing the best quality care for the patient.

All interprofessional team members will understand how to assess the patient’s level of pain using the patient-specific assessment tool to understand if QI initiatives were effective. The patient’s pain level will be measured and documented to monitor for additional unresolved pain over 24 hours. The team will be able to review the data being documented to ensure the patient has no pain levels over six for longer than 24 hours. Keeping the patient and the interdisciplinary team educated on the care plan and the pain treatment plan improves the patient’s quality of life. Maintaining a comfortable patient decreases the family’s stress, enhances the nurse’s satisfaction with work, and provides a sense of excellent interprofessional teamwork (Chi et al., 2018).

NURS FPX 6612 Assessment 2 Quality Improvement Proposal

Communication Strategies

Interprofessional communication strategies that will promote and ensure the success of the QI initiative include using the situation, background, assessment, and recommendation (SBAR) communication model.

Being a patient’s advocate is an essential part of nursing that requires nurses to speak up when they are concerned for their patient’s care. Several communication models have been created to organize nurses’ and other healthcare professionals’ concerns into action. A good communication strategy to direct attention to areas of concern is the SBAR communication technique. SBAR stands for situation, background, assessment, and recommendation.

The situation provides a brief understanding of what is going on and explicitly states the importance of the issue—next, the background on the issue about the current issue, with necessary information. The assessment describes what is going on that affects the situation and is noticed. Finally, a recommendation on how to handle the problem is suggested (Podgorny, 2022).

In this instance, the relatively high number of patients reporting 7 to 10 pain levels for over 24 hours is the situation. The background pertains to elevated pain being an adverse event lasting longer than 24 hours. The assessment states the data supports an increase in patients reporting seven out of ten pain from 2014 to 2015. Finally, the recommendation is to re-educate the nurses using the assessment tools, educate families on the importance of treating pain, and promote pain relief techniques by creating a patient-centered pain management care plan.

Conclusion

Not addressing pain management increases stress hormones released by the brain to respond to the body’s damage. When pain continues not to be managed, the body goes out of homeostasis and creates a never-ending loop of hormone release and an increase in pain reception. The endless loop of pain causes the body to increase the workload on the heart, lungs, and other major organs. Ultimately, the increase in pain increases depression and anxiety while decreasing the patient’s quality of life (Lee et al., 2019). While the proposal may be simple in providing a patient-centered treatment and education plan, it gives a universal recommendation that all healthcare members can advocate for their patient’s pain management and comfort in-home care and hospice care.

References

Agency for Healthcare Research and Quality. (n.d.). National Health Quality and Disparities Report. Retrieved April 26, 2022, from https://nhqrnet.ahrq.gov/inhqrdr/National/trend/table/Setting_of_Care/Home_Health- Hospice#improved

Azevedo-Santos, I. F., & DeSantana, J. M. (2018). Pain measurement techniques: spotlight on mechanically ventilated patients. Journal of pain research, 11, 2969–2980. https://doi.org/10.2147/JPR.S151169

Boamah, S. A., Spence Laschinger, H. K., Wong, C., & Clarke, S. (2018). Effect of transformational leadership on job satisfaction and patient safety outcomes. Nursing Outlook, 66(2), 180-189. https://doi.org/10.1016/j.outlook.2017.10.004

Chi, N., Demiris, G., Pike, K. C., Washington, K., & Oliver, D. P. (2018). Pain management concerns from the hospice family caregivers’ perspective. American Journal of Hospice & Palliative Medicine, 35(4), 601-611. https://doi.org/10.1177/1049909117729477

Creek, T. J. (2019). Pain assessment tools for the nonverbal critical care adult: An integrative review of the literature. [Master’s Thesis, Montana State University]. Scholar Works. https://scholarworks.montana.edu/xmlui/bitstream/handle/1/15765/creek-pain- assessment-2019.pdf?sequence=3&isAllowed=y

Lee, K. A., Bernacki, R., & Lakin, J. (2019). Quality indicators for pain in palliative care. Handbook of pain and palliative care. Springer International Publishing, 109-125. https://doi.org/10.1007/978-3-319-95369-4_7

Levy, N., Sturgess, J., Mills, P. (2018). “Pain as the fifth vital sign” and dependence on the “numerical pain scale” is being abandoned in the US: Why? British Journal of Anesthesia, 120(3), 435-438. DOI:https://doi.org/10.1016/j.bja.2017.11.098

McCoy, L., Lewis, J. H., Simon, H., Sackett, D., Dajani, T., Morgan, C., & Hunt, A. (2020). Learning to speak up for patient safety: Interprofessional scenarios for training future healthcare professionals. Journal of Medical Education and Curricular Development, 7, Doi: 2382120520935469. https://doi.org/10.1177/2382120520935469

National Coalition for Hospice and Palliative Care. (2019). Palliative care quality measures project: Evaluating patient and caregiver voices. https://www.nationalcoalitionhpc.org/qualitymeasures/

National Institute for Children’s Health Quality. (2022). Why data collection is a necessary part of quality improvement. https://www.nichq.org/insight/why-data-collection-necessary- part-quality-improvement#:~:text=Data%20collected%20to%20understand %20improvement,to%20reach%20the%20intended%20outcomes.

Pinheiro, A., & Marques, R. (2019). Behavioral Pain Scale and Critical Care Pain Observation Tool for pain evaluation in orotracheally tubed critical patients. A systematic review of the literature. Behavioral Pain Scale Critical Care Pain Observation. Revista Brasileira de terapia intensiva, 31(4), 571–581. https://doi.org/10.5935/0103-507X.20190070

Podgorny, K. (2022). SBAR (Situation, Background, Assessment, Recommendation). American Society for Quality. https://asq.org/quality-resources/sbar

Toney-Butler, T.J., Thayer, J.M. (2021). Nursing Process. StatPearls Publishing, 2022 (Jan). https://www.ncbi.nlm.nih.gov/books/NBK499937/

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Identify a quality improvement opportunity in your organization or practice. In a 1,250-1,500 word paper, describe the problem or issue and propose a quality improvement initiative based on evidence-based practice. Apply “The Road to Evidence-Based Practice” process, illustrated in Chapter 4 of your textbook, to create your proposal.