Strategic Implementation of Quality Initiatives

Scenario

You are the CEO of St. Thomas Regional Healthcare Center. Over the past five years, you lead significant quality improvement initiatives resulting in national recognition and Magnet status. You are invited to speak at a national quality improvement conference for other hospital leaders.

Instructions

“Complete a strategic plan and a complementing PowerPoint summary presentation”, which reflect your process of developing and implementing quality improvement initiatives.

Your strategic plan should include:

Summary of changes in healthcare quality improvement initiatives over the past 10 years and how they are influencing healthcare practices.
An analysis of state and national health care quality measures and the quality improvement principles used in developing your initiatives.
Discuss the Magnet model components and quality improvement initiatives developed to address patient safety outcomes.
Explain the quality improvement model used and strategies developed to address patient safety challenges healthcare.
Identify two quality improvement initiatives and strategies that include engaging healthcare staff as part of the initiative.
Summary of common threats to quality improvement in healthcare and apply a quality improvement model and strategies neutralizing the threats.

Create a PowerPoint presentation, with ”detailed speaker note” (USE POWER POINT TEMPLATE ATTACHED) for the conference that summarizes the strategic plan. All files have been attached for this assignement

Al” (USE POWER POINT TEMPLATE ATTACHED) for the conference that summarizes the strategic plan.l

Rubric Below:

A – 4 – Mastery

Strategic plan included a comprehensive summary of changes in healthcare quality improvement initiatives over the past 10 years and a comprehensive description of how quality improvement initiatives are influencing healthcare practices with supporting evidence

A – 4 – Mastery

Strategic plan included a comprehensive analysis of state and national health care quality measures and the quality improvement principles used in developing your initiatives and a comprehensive description of each quality improvement principle with supporting references.

A – 4 – Mastery

Clear and thorough discussion on components of Magnet Recognition Program and quality improvement initiatives developed to address patient safety outcomes.

A – 4 – Mastery

Clear and thorough evaluation of the one model of quality improvement and how it was used to address patient safety challenges including comprehensive descriptions of the model with multiple examples of how the model is used to address patient safety challenges.

A – 4 – Mastery

Comprehensive list of at least two quality improvement initiatives and strategies that include engaging healthcare staff as part of the initiative. Included multiple examples for each item on the list.

A – 4 – Mastery

Clear and thorough summary of the common threats to quality improvement Provided multiple supporting rationales for application of a quality improvement model and strategy to neutralize the threats.

A – 4 – Mastery

Clear and thorough: PowerPoint presentation, with either speaker’s notes or narration, about the process of developing and implementing quality improvement initiatives. Provided clear and thorough description for each sub-bullet of the strategic plan.

Deliverable #7 – HAS 6200

Who Am I? CEO of Healthcare center (you’ve been CEO for the past 5 years – achieved national recognition and magnet status under your leadership

What are you preparing for? To speak at a national conference for QI for hospital leaders – PPT

What is your PPT going to include? A COMPLETE strategic plan inclusive of the process of development and implementation of QIIs

Strategic Plan on PPT needs to include:

1. Summary of QII’s over

the past TEN years
and influence on HC policies

2. Analysis of State and National quality measures and QI principles used in developing your initiatives.
(GO BACK TO YOUR DELIVERABLE #2 FOR THIS INFORMATION!)

3. Magnet model components & QII’s developed to address patient safety outcomes. (GO BACK TO YOUR DELIVERABLE #3 FOR THIS INFORMATION).

4. Quality improvement model used and strategies developed to address patient safety challenges in healthcare. (GO BACK TO YOUR DELIVERABLE #4 for THIS INFORMATION).

5. Identify two quality improvement initiatives and strategies that include engaging healthcare staff as part of the initiative (GO BACK TO DELIVERABLE #5 WHERE YOU CAME UP WITH 3 INITIATIVES)

6. Summary of common threats to quality improvement in healthcare and apply a quality improvement model and strategies neutralizing the threats (GO BACK TO DELIVERABLE #6 FOR THIS INFORMATION).

7. PPT will need to consist of either speaker note). I would recommend using Screencast-o-matic because you can use your previous deliverables and speak some of that information over the slides they go along with – if you don’t write it down, it won’t pull for plagiarism – Be sure to put only KEY WORDS and PHRASES on each slide –
Rule of thumb is 5 bullet points per slide. Don’t forget to add a textbox in the lower right hand corner for in-text citations.

A strategic plan is a “future-oriented statement that presents all the information and data needed to determine the direction of a company or project. There are several elements that go into a corporate plan: vision, assumptions, objectives, information, analysis, measurement, evaluation, and opportunity” (Strategic plan, 2013).

Your assignment may specify which elements should be included in your strategic plan, so be sure to read it carefully. If it doesn’t, here are some general components in most strategic plans:

·
Analyze the current state of the organization or initiative. There are many tools out there to accomplish this; one of the most popular is a

SWOT analysis

·
Determine where you want to go. What issues are a priority to be addressed? How do they align with the mission or the organization or initiative?

·
Set goals for the organization or initiative. What do you want to achieve, and over what period of time?

·
Figure out who is accountable for reaching those goals. How are you going to achieve the goals? How much time and money needs to be allocated where in order to make this achievable?

What is a SWOT analysis?

A SWOT analysis is a tool used as a planning and brainstorming tool to organize information, identify issues, determine solutions, and suggest opportunities. It is used to determine how internal and external factors contribute to outcomes.

Strengths: Factors likely to have a positive effect

Weaknesses: Factors likely to have a negative effect

Opportunities: External factors that have not been previously considered and are likely to have a positive effect

Threats: External factors likely to have a negative effect

How do I create a SWOT analysis?

You can start by asking yourself these questions:

Strengths

· What do we do well?

· What are our strengths?

· What do others see as our strengths?

· What resources do we have that we can use?

· What would the community say we are best at providing?

· Do we have strong name recognition?

· Do we have a stable workforce?

Weaknesses

· What do we need to improve?

· What areas are less strong?

· What would others see as our weaknesses?

· What other resources are needed?

· What currently causes us trouble in providing exceptional care?

Opportunities

· What opportunities are open to you?

· How can we turn our strengths into opportunities?

· How can we eliminate our weaknesses?

· What other resources can we access?

· Who else can help us?

· What can we learn from others?

Threats

· What challenges/barriers are there

· How could our weaknesses become threats?

· Who could hinder us?

· What could make our goal unnecessary or unachievable?

How do I format a SWOT analysis?

The most common way to see a SWOT analysis presented is in a four-square model followed by an analysis of each section.

Strengths

· List your strengths here

· List your strengths here
· List your strengths here
· List your strengths here

Weaknesses

· List your weaknesses here

· List your weaknesses here
· List your weaknesses here
· List your weaknesses here

Opportunities

· List your opportunities here

· List your opportunities here
· List your opportunities here
· List your opportunities here

Threats

· List your threats here

· List your threats here
· List your threats here

Strengths

Write your in-depth strengths analysis here to provide insight into how you identified your strengths and what they mean for you as a provider.

Weaknesses

Write your in-depth weaknesses analysis here to provide insight into how you identified your weaknesses and what they mean for you as a provider.

Opportunities

Write your in-depth opportunities analysis here to provide insight into how you identified your opportunities and what they mean for you as a provider.

Threats

Write your in-depth threat analysis here to provide insight into how you identified your threats and what they mean for you as a provider.

Do you have any examples?

See the files below for examples.

References

Doucette, J. (2014). Leadership Q&A.
Nursing management, 45(10). https
: doi: 10.1097/01.NUMA.0000453945.08276.8c

Foundation of Nursing Studies. (2015). Swot analysis. Retrieved from https://www.fons.org/resources/documents/Creating-Caring-Cultures/SWOT-

Morrison, M. (2011, October 30). Swot analysis in nursing & health care. Retrieved from https://rapidbi.com/swot-analysis-in-nursing-health-care/

INDEED Strategic Plan Page Click HERE

What are strategic plan elements?

The elements you include in your strategic plan can vary depending on your purpose for creating a strategic plan. An example of this would be starting a business versus expanding into a new industry or product line. Here is a list of standard strategic planning elements to help you structure your own plan:

Vision statement

The vision statement is an important part of a strategic plan as it provides a short summary highlighting what your business will look like in the future.

Example:
To provide innovative technological solutions to businesses throughout the nation and the world.

Mission statement

The mission statement defines the purpose of your business within your industry or the world. The mission statement usually consists of your business’s main industries or target audiences, key products or services and what makes you different from your competitors.

Example:
At our company, we are committed to helping low-income families find the resources they need to get healthcare loans with no credit checks and low-interest payments.

Goals and objectives

Every strategic plan should include a goals and objectives section. You can include both short- and long-term goals as they relate to your overall business vision.

Example:

Short-term goals:

·
Hire five new employees within the next four months.

·
Increase sales quotas by 10% within the next six months.

·
Update internal communication systems to improve productivity.

·
Create and implement a three-month-long marketing campaign for a new product.

·
Increase market prices for products by 2% over the next four months.

Long-term goals:

·
Transition from the paper industry into the office supply industry within the next five years.

·
Expand to include three new retail locations within the next two years.

·
Pay-off debts by the end of next year.

·
Create an internal promotion program to keep talent within the company.

·
Enhance brand recognition by 15% through marketing and promotional events.

SWOT analysis

A SWOT analysis allows you to identify and list your business’s strengths, weaknesses, opportunities and threats. This is important as it allows you to determine potential challenges to achieving your business goals and what you need to do to overcome them.

Example: A regional clothing retailer’s SWOT analysis:

Strengths

·
Strong brand recognition and social media following

·
Excellent customer service

·
Skilled sales team

Weaknesses

·
Clothing quality

·
Frequent shipping errors

·
Limited marketing budget

Opportunities

·
Expansion into children’s clothing

·
Expansion into men’s clothing

·
Potential to open one location in another state

Threats

·
National clothing retailers nearby

·
Target customers outgrowing our styles

·
Economic down-turns reducing sales

Action plan

Using what you learned from your SWOT analysis, you can create an action plan. Action plans consist of strategies for achieving short- and long-term goals or objectives and overcoming challenges.

Example: Here is an example of an action plan for a business looking to expand their brand awareness:

Goal: To increase brand awareness by 10%

Action 1: Create social media accounts

·
*Individuals responsible: Social media marketing team*

·
*Resources needed: Access to digital photo libraries, creative software programs, social media posting calendar*

·
*Deadline: December 31, 2020*

Action 2: Plan and host three promotional events

·
*Individuals responsible: Marketing team, sales team and advertising team*

·
*Resources needed: outsourced event planning staff, event venue, print and visual advertisements, ticket sale locations*

·
*Deadline: March 20, 2021*

Action 3: Obtain additional funds for advertising and marketing budgets

·
*Individuals responsible: Marketing director*

·
*Resources needed: Financial advice, marketing proposal document*

·
*Deadline: April 15, 2021*

KPIs

KPIs or key performance indicators are measurable components that allow businesses to track the progress of particular initiatives in relation to business goals.

Examples:

· Net profit margin

· Gross profit margin

· Cash flow

· Employee turnover

· Employee satisfaction

· Employee productivity

· Cost per lead

· Monthly sales totals

· Product returns

· Customer turnover

· Customer satisfaction

· Return customer rate

How to write a strategic plan

Creating a strategic plan involves using an appropriate layout, format and elements to specify the company strategy. Here’s what you can include:

1. Consider the company mission

The mission for a business describes what the company does. Company leaders often establish a mission when creating a company and write it down for later reference. When creating a strategic plan at the onset of a business venture, founders might ask themselves what the main function of the business is and how it may impact the people or entities it serves.

Mission example:
To create and sell quality cupcakes

Related:

Why Is a Company Mission Statement Important?

2. Establish a communal vision

Company vision refers to the future goals of what the company may become. Establishing a communal vision for the company can help ensure everyone shares the same understanding of the company’s trajectory. Everything else that follows in your strategic plan may ultimately contribute to fulfilling the vision. This makes the vision statement particularly important because it can give you a sound objective on which to focus.

Vision example:
To be the most notable and successful cupcake shop in Seattle

Guide to Vision Statements

3. State key values

Company values represent how team members and the company as a whole may behave to work toward the communal vision. To state values, consider what the business does, who it serves and the founders’ motivations for starting the business. Values may be broad, with a word or two representing each.

Value examples:

·
Quality

·
Service

·
Atmosphere

·
Community

·
Teamwork

Core Values in the Workplace: 84 Powerful Examples

4. Develop focus areas

Focus areas are the high-priority elements the company plans to focus its efforts on in working toward its vision. For each value in the strategic plan, state a focus area to accompany that value. These focus areas may be more specific than the vision statement and include a quantifiable metric to achieve. It may be ideal for creating between three and five different focus areas per value to maintain company focus.

Here are some examples of focus areas for a cupcake shop:

Examples:

·
Best cupcakes in town

·
Refined ingredients

·
Healthy desserts

14 Types of Business Growth Explained

5. Create specific objectives

At this point in the planning process, you may be ready to create specific objectives representing what the company wants to accomplish. These objectives will likely help guide the rest of your strategic plan and keep a company on schedule to meet and exceed expectations. Consider using three to six objectives to define your aim. Each may align with one or more of the focus areas. It can also be helpful to include specific deadlines and success markers to measure.

Objective example:
Expand menu section for healthy dessert options by December 31, 2023

13 Best Business Objectives To Consider (Plus Tips)

6. Describe projects

Listing specific projects that the company can complete to accomplish its objects can add action to a strategic plan. Effective strategic plans may pair each objective with an actionable project. The project may clearly detail how you plan to achieve the corresponding objective.

Project example:
Create contracts with local farmers for organic foods and ingredients by June 30, 2023

What Is a Business Project? (Plus Tips for Executing Them)

7. Define key performance indicators

Key performance indicators are measurable values demonstrating how effectively a business achieves its objectives. This means that KPIs can help evaluate the success of each objective and project in your plan. The best KPIs may be measurable and specific to the goal they evaluate.

KPIs are also important because they serve as communication in business. In addition to helping individuals within a company assess their progress, they can inform other business leaders of a company’s advancement toward reaching a key business objective.

KPI examples:

·
Percentage growth in sales

·
Percentage growth in new markets

·
Number of new partnerships

·
Number of healthy menu items

Key Performance Indicators (KPIs): Definition and Examples

Elements to include in a strategic plan

Here are some key elements to include while creating a strategic plan:

·
Executive summary: An effective executive summary may include a mission and vision statements, values, and objectives for the business. This section may be a brief overview.

·
Signature page: This page includes signatures from the board of directors or senior management, marking approval for the strategic plan.

·
Company description: This section outlines the business’ history and reason for existing. It can also include products and services it provides or relevant business accomplishments.

·
Mission, vision and value statements: In your mission, vision and value statements, describe what the company is doing now and what it may accomplish in the future. The values provide the reader a sense of key priorities in the organization.

·
Strategic analysis: This section gives an overview of the business’ strengths, weaknesses, opportunities and threats (SWOT analysis) from both internal and external perspectives. It can be helpful to identify areas where the company might benefit from growth and describe actionable plans for each area.

·
Action plan: The action plan presents objectives and projects. This shows readers how the company plans to improve and demonstrates quantifiable goals.

·
Budget and operating plans: The budget plan details resources and funding necessary to achieve the strategic goals. This section can also list the KPIs and projections for growth that the company hopes to see.

Author’s Last Name, First Initial. Middle Initial. (Year, Month day).
Webpage or article title. Website Name.

https://URL

Mahon, J. (2020, May 6).
COVID-19: Agriculture’s ominous feeling about the pandemic. Federal Reserve Bank of Minneapolis.

https://www.minneapolisfed.org/article/2020/covid-19-agricultures-ominous-feeling-about-the-pandemic

Strategic Implementation of Quality Initiatives

Presenter:

2/15/2023

Course

Contents

10 Years of QIIs and Influence

State and National QI Measures and Principles

Magnet Model & QII’s for Patient Safety

QI Model & Strategies for patient safety

QII’s (2) & strategies to engage healthcare staff

Common threats to QI and Qi model application to neutralize threats

Strategic Plan

10 Years of QIIs and Influence

(In-text Citations Go); (Ide, 2023); (CDC, 2022)

Point #1

Point #2

State and National QI Measures and Principles

(In-text Citations Go); (Ide, 2023); (CDC, 2022)

Point #1

Point #2

Magnet Model & QII’s for Patient Safety

Point #1
Point #2
#3
#4
#5
(In-text Citations Go); (Ide, 2023); (CDC, 2022)

QI Model & Strategies for patient safety

Point #1
Point #2
#3
#4
#5
(In-text Citations Go); (Ide, 2023); (CDC, 2022)

QII’s (2) & strategies to engage healthcare staff

Point #1
Point #2
#3
#4
#5

(In-text Citations Go); (Ide, 2023); (CDC, 2022)

Common threats to QI and Qi model application to neutralize threats

(In-text Citations Go); (Ide, 2023); (CDC, 2022)

Point #1

Point #2

Strategic Plan – Mission & Vision

Point #1
Point #2
#3
#4
#5
(In-text Citations Go); (Ide, 2023); (CDC, 2022)

Strategic Plan – Values
Point #1
Point #2
#3
#4
#5
(In-text Citations Go); (Ide, 2023); (CDC, 2022)

Strategic Plan – Review of QIIs
Point #1
Point #2
#3
#4
#5
(In-text Citations Go); (Ide, 2023); (CDC, 2022)

Strategic Plan SWOT analysis

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4
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(In-text Citations Go); (Ide, 2023); (CDC, 2022)
(In-text Citations Go); (Ide, 2023); (CDC, 2022)
(In-text Citations Go); (Ide, 2023); (CDC, 2022)
(In-text Citations Go); (Ide, 2023); (CDC, 2022)

References

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Running head: WHITE PAPER 1

Deliverable Two: Cost, Quality and Access of Care

LaToya T. Benson

Rasmussen University Online

Healthcare Quality Management

January 29, 2023

Dr. Ide

Cover Letter

January 29, 2023

To: Professor Dawn Ide, Chief Medical Officer (CMO)

From:

LaToya T. Benson, Senior Clinical Analyst

Re: Cost, Quality, Access of Care of Nursing Homes

Enclosed is the white paper on the quality improvement initiative for the next fiscal year. After further evaluating Oakridge Health Systems’ last year’s annual survey findings compared to the state and national healthcare data statistics, these are this report’s three main focal points:

(1) Quality measures are tools that help us measure patient outcomes, perceptions, and organizational structure and systems associated with the ability to provide high-quality health care and that relate to one or more quality goals for health care.

(2) Improving healthcare quality and safety is a growing focus for the nursing field and healthcare systems, as medical institutions aim to achieve efficiency, reduce healthcare costs and ensure high-quality patient outcomes.

(3) Bedsores are a severe healthcare problem and the target of care quality reform. Taking some simple steps can reduce the chance of pressure ulcers developing. Bedsores are a crucial indicator of the quality and experience of care.

I would like to will schedule a meeting so that we can further discuss the report. Please respond by end of the next business day.

Sincerely,

LaToya T. Benson, Senior Clinical Analyst

Executive Summary

Nursing facilities are part of the long-term care delivery system that includes home and community-based services (Harrington, 2018). Still, their relatively high cost has led them to be the focus of much attention from policymakers. As the COVID-19 pandemic continues to ravage the country, widespread financial challenges loom over many long-term care facilities (Harrington, 2018). One of the root causes of these challenges is Medicaid underfunding. Medicaid plays a significant role in financing nursing facility care in the United States. Policy proposals to limit federal financing for Medicaid may lead to cuts in eligibility or scope of coverage for long-term care services (Harrington, 2018). With Medicaid as the primary payer for most nursing facility residents, policy and payment for nursing facility care is a priority policy area for state and federal governments that finance it. Changes to federal Medicaid financing could have repercussions for states’ ability to maintain Medicaid spending for long-term services and support. In addition, regulations effective November 2016 aimed to address longstanding challenges in quality and safety in nursing facilities (Harrington, 2018). As the demand for long-term care continues to increase and policy proposals and regulations unfold, facilities’ characteristics, capacity, and care quality remain subjects of concern among consumers and policymakers. Nursing facilities provide care to prevent problems and address residents’ needs, but sometimes care must meet established standards. State surveyors assess the process and the outcomes of nursing facility care for individual requirements across significant areas. When a facility fails to meet a requirement, a citation is given to the facility for that requirement. This report analyzes the state of Illinois and national healthcare quality based on health deficiencies in the most recent year of data reported by the Centers for Medicare & Medicaid Services with supporting examples. Along with the recommendation for an initiative based on deficiencies and an evaluation of the quality measure outcomes.

Background/Explanation of the problem

The COVID-19 pandemic has put longstanding problems in Illinois nursing homes into the spotlight. Since the pandemic started, Illinois skilled nursing and residential care facilities have lost at least 14% of the workforce, and violations have increased (“Miletich,”.n.d.). According to a new report from an advocacy group, Illinois is the third worst state in the country for nursing home quality (“Nursing home report cards,” n.d.). According to the report, about 97 percent of nursing homes in Illinois had federal deficiencies or citations, and nearly 28 percent had severe shortcomings (“Nursing home report cards,” n.d.). According to a recent Families for Better Care report in 2019, Illinois ranks 42nd out of the fifty states in the U.S., with an overall grade of “F” because of its poor nursing home conditions. See the image below:

The Illinois Medicaid program pays for the care of about 70 percent of all the nursing home residents in the state, or roughly 45,000 seniors and disabled individuals (“Nursing home report cards,” n.d.). Many Illinois nursing homes, however, are challenged by low payments from Medicaid. Nursing homes hope the state’s newly adopted budget will offer relief. The budget includes another $240 million for Medicaid funding for nursing homes, including $70 million for staffing. It also has potential financial penalties for nursing homes that fail to meet staffing requirements.

Discussion/Analysis

A nursing home’s failure to meet a federal participation requirement is defined as a deficiency (“Nursing home enforcement,”.n.d.). Deficiencies range in scope and severity from isolated violations with no actual harm to residents to widespread violations that cause injuries or put residents in immediate jeopardy of harm (“Nursing home enforcement,”.n.d.). Deficiencies may be cited because of an on-site inspection or evaluation of written reports or documentation. Some examples of deficiencies include:

· A nursing home did not provide a fluid and potassium-restricted diet to a resident who had end-stage renal disease.

· A resident reported to multiple nursing home staff that another resident had made threats to return to the nursing home to shoot and stab nursing home staff once he was discharged. The nursing home did not report the threat to a law enforcement entity and take other appropriate actions.

· A doctor ordered that a nursing home should not give medications to a resident when the resident’s systolic and diastolic blood pressures were less than 100 and 60, respectively. However, for 14 days in a month, the nursing home gave the medications to the resident when the resident’s systolic blood pressure fell below the ordered parameter of 60.

According to the state and national data set in the Centers for Medicare & Medicaid Services for the quality measure, staffing, and the number of deficiencies, Illinois’s health deficiencies are more significant than the nation. In Cycle 1, the nation averaged 8.4 health deficiencies, and Illinois had 11.5 health deficiencies. In Cycle 2, the nation averaged 8.6 health deficiencies, and Illinois had 10.8. In Cycle 3, the nation averaged 8.1, and Illinois had 9.4. Although health deficiencies were declining from Cycle 1-3, Illinois’s numbers remained more significant than the nation. See the figure below:

The data set does not describe Illinois’s type of health deficiencies. However, according to Medicare.gov, within a 5-50-mile radius in Illinois, the most common deficiency in nursing homes is abuse (“Medicare.gov,”.n.d.). Therefore, the number of health deficiencies in Illinois could represent abuse. Neglect is a form of abuse. For example, a resident can develop severe bedsores when left in their feces due to neglect. Another example is medication errors. The nursing staff may make mistakes when giving medications to residents, such as administering the wrong medication. Another example is dehydration and malnutrition. Nursing home staff members may not provide enough food or water to residents. Based on this analysis, one quality measure initiative I recommend for Oakridge Health System is decreasing bedsores/bedsore prevention. Bedsores are a crucial indicator of the quality and experience of care (“Bedsores associated with Nursing Home Abuse and neglect,”. n.d.). According to the Centers for Disease Control (CDC), as many as one out of 10 residents in nursing homes currently suffer from bedsores, and studies show that they get them twice as often as hospital patients (Centers for Disease Control and Prevention, 2015). Preventing bedsores is essential to protect patients from harm and reduce the costs of caring for them (“Bedsores associated with Nursing Home Abuse and neglect,”. n.d.) Bedsores can also lead to bodily sepsis, nerve damage, dehydration, malnourishment, and even death.

Recommendations

The primary focus of quality improvement in healthcare is promoting patient safety and avoiding patient injuries. Therefore, since bedsores are one of the most common but severe complications in nursing homes, I recommend that Oakridge Health Systems develop a Bedsore Prevention Program to reduce the prevalence of bedsores. Preventing this problem is essential to protect patients from harm and reduce the costs of caring for them. This program will consist of the following:

1. Skin Assessment: A skincare assessment will be completed for new nursing home residents within 14 days of admission to the facility to help determine what factors may put the resident at risk for developing bed sores (“What are nursing homes required to do to prevent bed sore,”.n.d.) Identifying specific risk factors helps the nursing home staff determine which preventative measures should be for each resident.

II. Repositioning and Reduction: If a resident is identified as at risk for a bedsore development or a bedsore risk assessment score indicates that the person is at stake, then a preventive intervention addressing repositioning needs and pressure reduction must be instituted (“What are nursing homes required to do to prevent bed sore,”.n.d.) Within 12 hours, reducing or eliminating risk factors can prevent pressure ulcer formation.

III. Nutrition: If a resident is identified as at risk for pressure ulcer development and has malnutrition (involuntary weight loss of ≥ 10% over one year or low albumin or albumin levels), then nutritional intervention or dietary consultation should be instituted because a poor diet, deficient dietary protein intake, is an independent predictor of pressure ulcer development (“What are nursing homes required to do to prevent bed sore,”.n.d.)

IV. Increase Nursing Staff: Higher nurse staff levels in nursing homes are one of the essential things a facility can do to improve the quality of care and life (“Nurse-patient ratios as a patient safety strategy,”.n.d.)
When the nursing staff is overworked and caring for too many patients, they may be forced to prioritize what they do and who they help (“Nurse-patient ratios as a patient safety strategy,”.n.d.). Therefore, they can be left in one position for too long and develop bedsore that rapidly worsens and triggers a cascade of complications such as infection, hospitalization, and disability.

V. Staff Education: Healthcare staff should be educated on stopping and managing pressure sores. If they hold the knowledge, it could be one way of helping to care for the patient. Also, educating healthcare professionals on pressure ulcer prevention may lead to better patient care.

Conclusion

Bedsores are significant health issues and one of the biggest challenges nursing homes faces on a day-to-day basis. Aside from the high cost of treatment, bedsores also significantly impact patients’ lives and the provider’s ability to render appropriate care to patients. Preventing bedsores has always been a challenge for caregivers and the healthcare industry as a whole because the epidemiology of bedsores varies by clinical setting and is a potentially preventable condition. The development of pressure ulcers or injuries can interfere with the patient’s functional recovery, may be complicated by pain and infection, and can contribute to more extended hospital stays. Between deficiencies, treatment costs, and financial losses, there are incentives for nursing homes to improve the quality of care and prevent the creation of pressure sores in patients.

References

Bedsores associated with Nursing Home Abuse and neglect. Hupy and Abraham, S.C. (n.d.). Retrieved January 29, 2023, from

https://www.hupy.com/library/bedsores-associated-with-nursing-home-abuse-and-neglect.cfm

Charlene Harrington, H. C. (2018, April 3).
Nursing facilities, staffing, residents and facility deficiencies, 2009 through 2016. KFF. Retrieved January 29, 2023, from

Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2016

Centers for Disease Control and Prevention. (2015, November 6).
Products – data briefs – number 14 – February 2009. Centers for Disease Control and Prevention. Retrieved January 29, 2023, from https://www.cdc.gov/nchs/products/databriefs/db14.htm.

Medicare.gov. (n.d.). Retrieved January 29, 2023, from https://www.medicare.gov/care-compare/results?searchType=NursingHome&page=3&city=Hazel+Crest&state=IL&zipcode=60429&radius=25&sort=closest.

Miletich, M. (n.d.).
Patients matter most: Illinois could drastically change struggling nursing home system. https://www.25newsnow.com. Retrieved January 29, 2023, from

https://www.25newsnow.com/2021/11/22/patients-matter-most-illinois-could-drastically-change-struggling-nursing-home-system/

Nursing home enforcement. CMS. (n.d.). Retrieved January 29, 2023, from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationEnforcement/Nursing-Home-Enforcement.

Nursing home report cards. Nursing Home Report Cards Families For Better Care. (n.d.). Retrieved January 29, 2023, from

https://familiesforbettercare.com/index.php/report-cards

PG;, S. (n.d.).
Nurse-patient ratios as a patient safety strategy: A systematic review. Annals of internal medicine. Retrieved January 29, 2023, from https://pubmed.ncbi.nlm.nih.gov/23460097/.

What are nursing homes required to do to prevent bed sores? What are nursing homes required to do to prevent bed sores? – Nursing Home Law Center. (n.d.). Retrieved January 29, 2023, from https://www.nursinghomelawcenter.org/what-are-nursing-homes-required-to-do-to-prevent-bed-sores.html.

Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2016

https://familiesforbettercare.com/index.php/report-cards

https://www.25newsnow.com/2021/11/22/patients-matter-most-illinois-could-drastically-change-struggling-nursing-home-system/

https://oig.hhs.gov/oas/reports/region9/91802010

https://www.medicare.gov/care-compare/results?searchType=NursingHome&page=3&city=Hazel%20Crest&state=IL&zipcode=60429&radius=25&sort=closest

https://www.hupy.com/library/bedsores-associated-with-nursing-home-abuse-and-neglect.cfm

https://www.acpjournals.org/doi/10.7326/0003-4819-135-8_part_2-200110161-00014

https://studycorgi.com/staff-education-on-pressure-ulcers-prevention/

Illinois Health Deficiences versus the Nation

NATION

Cycle 1 Total Number of Health Deficiencies Cycle 2 Total Number of Health Deficiencies Cycle 3 Total Number of Health Deficiencies 8.4 8.6 8.1 IL

Cycle 1 Total Number of Health Deficiencies Cycle 2 Total Number of Health Deficiencies Cycle 3 Total Number of Health Deficiencies 11.5 10.8 9.4

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MAGNET RECOGNITION PROGRAM

Presenter:

LaToya T. Benson, Clinical Analyst

Brief history of Magnet Recognition Program

In December 1990, the American Nurses Association (ANA) Board of Directors approved creation of the Magnet Hospital Recognition Program for Excellence in Nursing Services (“History of the magnet recognition program,” n.d.). Based on a 1983 study by the American Academy of Nursing (AAN), the program identified characteristics of healthcare organizations that excelled in recruiting and retaining registered nurses (“History of the magnet recognition program,” n.d.). The ANCC initiated a pilot program involving five hospitals in Seattle in 1994. ANCC awarded the first Magnet recognition to the University of Washington Medical Center three years later. In 1997, ANCC changed the program’s official name to the Magnet Nursing Services Recognition Program (“History of the magnet recognition program,” n.d.).

Magnet History Timeline

1983
The American Academy of Nursing (AAN) Task Force on Nursing Practice in Hospitals conducted a study to identify work environments that attract and retain well-qualified nurses who promote quality patient, resident and client care. Forty-one of 163 institutions possessed qualities that enabled greater capacity to attract and retain nurses and were therefore described as “magnet” hospitals. The characteristics that distinguished these organizations from others are known to this day as the “Forces of Magnetism.”(About magnet, 2019)
1990
June. The American Nurses Credentialing Center (ANCC) was incorporated as a subsidiary nonprofit organization through which the American Nurses Association (ANA) offers credentialing programs and services. (About magnet, 2019)
December. The ANA Board of Directors approved a proposal for the Magnet Hospital Recognition Program for Excellence in Nursing Services, building upon the 1983 magnet hospital study conducted by the AAN. .”(About magnet, 2019)
1994
The University of Washington Medical Center, Seattle, WA, became the first ANCC Magnet-designated organization. (About magnet, 2019)
1997
The program became known as the Magnet Nursing Services Recognition Program and qualification criteria were revised using The Scope and Standards for Nurse Administrators (ANA, 1996).
1998
Magnet expanded to include long-term care facilities. (About magnet, 2019)
2000
Magnet expanded to recognize health care organizations outside the US. .”(About magnet, 2019)
2002
The program name officially changed to Magnet Recognition Program®..”(About magnet, 2019)
2007
ANCC commissioned a statistical analysis of Magnet appraisal team scores from evaluations conducted using the 2005 Magnet Recognition Program ® Application Manual. This analysis clustered the Standards of Excellence into more than 30 groups, yielding an empirical model for the Magnet Recognition Program .”(About magnet, 2019)
2008
The Commission on Magnet introduced a new vision, and a new conceptual model that grouped the 14 Forces of Magnetism (FOM) into five key components: Transformational Leadership; Structural Empowerment; Exemplary Professional Practice; New Knowledge, Innovations, & Improvements; and Empirical Outcomes. (About magnet, 2019)

2000

2002

2007

2008

2011

1983

1990

1994

1997

1998

Five Magnet Model Components

Transformational leadership refers to the ability to adjust to changing demands within the healthcare industry by updating an organization’s behaviors, values, and processes when necessary (“Achieve & Maintain Magnet Status, “. n.d.). For example, a nurse leader with a transformational style would find creative ways to inspire staff with a vision for the future, including meeting with groups of staff or using staff e-mails to lay out goals and methods of reaching them. Structural empowerment means that nurses in a facility can contribute to establishing the standards and processes they use at work (Moura et al. 2020). For example, nurses gain access to support by receiving feedback and guidance from subordinates, colleagues, and superiors, which enables autonomous decision-making. Access to resources involves the nurses’ ability to obtain the supplies, resources, and materials needed to achieve the organizational goals (Moura et al. 2020). Exemplary professional practice refers to nursing practices that showcase effective patient care and highlight the nursing staff’s willingness to dedicate extra time and work to ensure each patient receives the care they need (“Achieve & Maintain Magnet Status, “. n.d.). For example, a nurse pursuing her master’s degree works full-time, coordinates activities for the unit (such as a Christmas party) and is involved with the unit-based practice council and many outside projects. She strives to help and provide for the community. The presence of new knowledge, innovation, and improvements are typically the primary goals of a Magnet organization, so identifying them during the evaluation process is an essential element of the Magnet model (“Achieve & Maintain Magnet Status, “. n.d.). For example, for nurses, new knowledge takes place through education, research, debating, and clinical learning. A predictive model is a nursing innovation (“Innovation in nursing, “. n.d.). The model relies on an algorithm to identify patients at risk for decline while hospitalized so that staff can proactively treat them and prevent patient mortality innovation (“Innovation in nursing, “. n.d.). An example of an improvement is a plan to reduce postoperative infections or uses data-driven approaches to shorten the average length of hospital stays. The final component of the Magnet model is empirical outcomes. This standard focuses on determining how solid processes and structures can positively impact the nursing staff, the entire organization, and the care systems (“Achieve & Maintain Magnet Status, “. n.d.). For example, through observation and practice, nurses learn how to find veins, insert intravenous fluids or medications, check vital signs, give immunizations, and aid doctors in medical procedures.

Transformational Leadership

Structural Empowerment

Exemplary Professional Practice

New Knowledge, Innovation, Improvements

Empirical Quality Results

Why become Magnet Status

The Magnet Recognition Program provides a roadmap to advance nursing excellence, with contented staff at its core. Optimum job satisfaction results in lower nurse attrition and an improved patient experience (Moody, 2021). To attract and reward the best in nursing talent, Magnet-recognized organizations embody a collaborative culture where nurses are valued as integral partners in the patient’s safe passage through their healthcare experiences (Moody, 2021). Magnet status is a designation for hospitals committed to providing outstanding healthcare services. These hospitals offer nurses continued or advanced educational opportunities to develop or improve their skills while gaining more knowledge about patient care. Also, magnet status can lead to better work environments for nurses and improved patient outcomes. For example, magnet hospitals are better able to attract the best nurses and retain these employees, resulting in improved patient care and satisfaction and lower mortality rates (Moody, 2021). These hospitals also report improved financial success and a competitive advantage in regional markets.

Lower nurse dissatisfaction and nurse burnout

Higher nurse job satisfaction

Lower registered nurse (RN) turnover

advanced educational opportunities

improved patient outcomes

Demographic Data Collection Tool (DDCT)

(“Demographic Data Collection Tool Data Elements collected,”.n.d.)

This Demographic Data Collection Tool (DDCT) is a web-based portal for managing the compilation of the required demographic data into a report (“DDCT – American Nurses Association,”.n.d.). This report is submitted to the Magnet Program office by the fifteenth of the month (or the next business day) before Written Documentation submission for initial or redesignating organizations. The ANCC awards Magnet recognition status for four-year terms. Upon receiving Magnet designation, however, hospitals must continue to follow program guidelines and complete interim monitoring requirements established by the ANCC. By predetermined annual deadlines, facilities must submit Demographic Data Collection Tool Reports (“DDCT – American Nurses Association,”. n.d.). During the second interim year, facilities must submit an Interim Monitoring Report and complete a series of phone conversations with a Magnet analyst (“DDCT – American Nurses Association,”.n.d.).The Magnet Commission may require a site visit or additional data if facilities no longer meet program guidelines and standards.
6

Data Collection

Magnet designation applicants must collect nurse-sensitive quality indicators at the unit level and benchmark that data against a database at the highest/broadest level possible (i.e., national, state, specialty organization, regional, or system) to support research and quality improvement initiatives ( Eligibility criteria, 2019). For example, nurse-sensitive quality indicators such as patient fall with and without injuries, RN satisfaction survey, Nosocomial infections, and Nursing hours per patient day are specific patient outcomes influenced by nursing care (Moody, 2021). These measures monitor the quality of care and patient safety at hospitals nationwide (Moody, 2021). The purpose is to collect applicable and value-added data for the particular unit and organization. Organizations must contribute their data (patient and nurse satisfaction, clinical nurse sensitive indicators) to a national database that compares the organization’s data against cohort groups at the national level (Eligibility criteria, 2019).
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nurse-sensitive quality indicators

benchmark that data

support research and quality improvement initiatives

collect applicable and value-added data

Four Goals that align to Magnet status

I. Improve medication adherence -Taking your medicine as prescribed or medication adherence is essential for controlling chronic conditions, treating temporary conditions, and overall long-term health and well-being. Studies have shown that patients with good adherence to treatment had a lower mortality rate.
II. Improve finances with cost-effective tools- Cost-effectiveness can help compare the health and cost impacts of different interventions affecting the same health outcome. It can also help understand how much an intervention may cost
III. Enhance provider relations and staff retention – Improving employee retention allows organizations to avoid the high cost associated with replacing employees, improves patient care, and enhances the overall quality of service to the communities served.
IV. Enhance patient engagement and satisfaction- Engaging patients in collaborative care, shared decision-making with their providers, and chronic disease self-management have improved health outcomes, increased functioning, reduced pain, and decreased costs.

Improve medication adherences

Improve financials with cost-effective tools

Enhance provider relations and staff retention

Enhance patient engagement and satisfaction

References

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Running head: EXECUTIVE SUMMARY 1

Deliverable Four: Executive Summary

LaToya T. Benson

Rasmussen University Online

Healthcare Quality Management

February 19, 2023

Dr. Dawn Ide

Purpose

The second highest priority in healthcare across a is patient satisfaction. Patient satisfaction begins the moment the patient steps in the

hospital

door. Patient satisfaction is an essential and commonly used indicator for measuring healthcare quality. It indicates how well the patient’s experience was at your medical practice. The “how well” refers not only to the quality of care but also to how happy patients are with the treatment they receive. It measures care quality and gives healthcare providers valuable insights into various aspects of healthcare, including their care’s effectiveness and level of understanding (Patient satisfaction, 2019). Patient satisfaction affects clinical outcomes, patient retention, and medical malpractice claims. It affects quality health care’s timely, efficient, and patient-centered delivery (Prakash, 2010). Response to call lights has also been associated with patient satisfaction. Delayed responses to answering call lights may result in a patient falling and can affect patient satisfaction. This paper discusses how the call button response time can improve and meet quality standards in the appropriately selected quality improvement model.

Problem

The University Medical Center’s most recent survey showed a 5% decline in overall patient satisfaction. Based on a review of the survey data, slow response time to call buttons ranked highest regarding the source of dissatisfaction among patients. There could be many reasons for the decline in customer satisfaction at the University Medical Center. For example, COVID-19 has played a significant role in the fall in customer satisfaction, especially in long-term facilities. Healthcare workers were exposed to substantial physical and mental burdens during the COVID-19 pandemic due to a lack of shortages and resources. Another example could be the using an old call light system. Long-term care facilities still using old call light systems risk the continuation of usability issues that can affect the performance of the staff and contribute to a decrease in patient satisfaction (Ali & Li, 2020). Another example could be lack of consistent rounding of patients.

The Plan-Do–Study–Act (PDSA)

The University Medical Center can consider several quality improvement models and frameworks to promote success. However, I recommend the Plan-Do-Study-Act (PDSA) method, a systematic series of steps for gaining valuable learning and knowledge for the continual improvement of a product, service, or process (“MQII principles and models of quality improvement”, n.d.) See Figure below:

The Plan-Do-Study-Act (PDSA) method is a way to test a change that is implemented. Going through the prescribed four steps guides the thinking process into breaking down the task into steps and then evaluating the outcome, improving on it, and testing again (“Plan-do-study-act (PDSA) directions and examples. AHRQ.” n.d.). For example, if your objective is to maximize your staff’s quality of work life, you might find evidence by surveying employees on workplace stressors. Another example is that the PDSA may elicit better interaction with electronic health records (EHRs) and EHR alerts, which, in turn, may yield more efficiency and improved cost of care, as well as better patient outcomes. Another example is that a healthcare organization can use PSDA to implement solutions to enhance and expand telehealth services.

Results of analysis

The University Medical Center’s most recent survey showed a 5% decline in overall patient satisfaction based on a slow response time to call buttons. The call button response time can be met with the Plan-Do-Study-Act (PDSA) method by implementation and evaluation of a purposeful rounding (PR) protocol with the following steps:

·
Plan: The Chief Quality Officer and quality team will decide how the new purposeful rounding (PR) practices will be implemented and monitored. These purposeful rounding practices will be developed around the 5 Ps of nursing called pain, position, potty (or personal hygiene), periphery and pump.

·
Do: In this stage, the staff is educated on these new practices. Following staff education, the emphasis will be on being intentional while completing tasks to meet patients’ needs and expectations. The quality team will monitor the implementation and ensure that nursing staff effectively achieves PR by rounding with staff and collecting relevant insights from patient interviews.

·
Study: Post-intervention data and observations, including patient satisfaction, patient interview, chart audit, and call light data results, will be collected to assess the effectiveness of the PR protocol in this stage.

·
Act: The data collected and analyzed from the study stage will be measured to determine if patient satisfaction has improved or declined.

Purposeful rounding protocols have been shown to improve the quality of care in hospitals, reduce the number of falls and injuries among patients, and reduce the number of

hospital-acquired infections

. Rounding on patients every hour is to address patients’ needs proactively. By doing so, we increase the quality of the patient’s experience and improve patient satisfaction.

Recommendations

Every interaction and every service provided is an opportunity to impact the patient’s experience. However, every healthcare facility may have a unique culture, whether full service or specialties, one thing that ties all healthcare systems together is the patients. The staff is the backbone of the organization. Therefore, we must engage the staff and patients to create a patient-centric practice and improve patient satisfaction. For example, to get the best out of our staff, we need to clearly define the purpose and goals of the purposeful rounds protocol (“10 ideas to engage your staff in a stellar patient experience,” n.d.).

Another example is to engage staff in the specific area of the 5 Ps of nursing called pain, position, potty (or personal hygiene), periphery, and pump. Training all staff on consistent practices will make patients feel comfortable each time they visit, whether they see the same nursing staff as they did during their last visit protocol (“10 ideas to engage your staff in a stellar patient experience,” n.d.). Another example of engaging the patient and staff is by encouraging customer feedback. Employees will be more motivated to serve patients since their performance will be directly reflected in surveys, online reviews, comment cards, etc. protocol (“10 ideas to engage your staff in a stellar patient experience,” n.d.). Another example of engaging staff is recognizing your high performers—incentivize staff by offering rewards or bonuses to top-performing staff members. The last example of increasing patient satisfaction is open communication between the medical team, patients, and families. This can broaden perspectives, provide new information, and reduce persistent emotional impacts and avoidance of doctors/facilities involved in the error or release of medical care in general.

References

10 ideas to engage your staff in a stellar patient experience. (n.d.). Retrieved February 20, 2023, from https://rollens.com/10-idea-to-engage-your-staff-in-a-stellar-patient-experience/.

Ali, H., & Li, H. (2020, March 27).
Use of notification and Communication Technology (call light systems) in nursing homes: Observational study. Journal of medical Internet research. Retrieved February 19, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7148550/.

MQII principles and models of quality improvement – malnutrition.com. (n.d.). Retrieved February 19, 2023, from http://malnutrition.com/static/pdf/mqii-principles-and-models-of-quality-improvement .

Patient satisfaction – why it matters and how to improve it. Healthcare Marketing Agency. (2019, July 28). Retrieved February 18, 2023, from https://www.practicebuilders.com/blog/patient-satisfaction-why-it-matters-and-how-to-improve-it/.

Plan-do-study-act (PDSA) directions and examples. AHRQ. (n.d.). Retrieved February 19, 2023, from https://www.ahrq.gov/health-literacy/improve/precautions/tool2b.html.

Prakash, B. (2010, September).
Patient satisfaction. Journal of cutaneous and aesthetic surgery. Retrieved February 18, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047732/#:~:text=Patient%20satisfaction%20is%20an%20important,delivery%20of%20quality%20health%20care.

The 5 P’s of Nursing

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A Quality Improvement Strategy and Training

Presenter: LaToya T. Benson

PAGE 1

Table of Contents

QI Goal
QI Objective
3 Initiatives
“Initiative” for Staff Training (name initiative you choose here)
Training
Background to training
i. Analysis of the need for diversity & inclusion awareness
ii. Value of cultural competence in QI
iii. Relationship of patient satisfaction & employee satisfaction related to D & I

A training activity related to cultural competence and QI a culture competency training activity called “Two Truths and A Lie”
PAGE 2

Quality Initiative Goal
To provide the highest quality of care to every patient, regardless of race, ethnicity, cultural background.
PAGE 3

This quality improvement goal aims to create an environment of respect and inclusivity for patients and staff by promoting diversity and inclusion (How to improve cultural competence in health care. School of Public Health, 2022).To achieve this goal, healthcare organizations should engage staff in activities that promote diversity and inclusion, such as providing cultural competency training, developing policies that support diversity, and fostering an environment where all staff members feel comfortable and respected (How to improve cultural competence in health care. School of Public Health, 2022). By taking these steps, healthcare organizations can create a more welcoming environment for all patients and staff, improving patient and employee satisfaction.
3

Quality Initiative Objective
To break down barriers that get in the way of patients’ receiving the care they need. It also strives to ensure improved understanding between patients and their providers.
PAGE 4

This quality improvement goal aims to improve communication better the provider, patients, and staff to keep patients safer. Communicating effectively with patients and families is paramount for good patient care (Ladha et al., 2018). Cultural competence includes providing effective health care across diverse cultures by working collaboratively and communicating effectively (Ladha et al., 2018). For example, physicians aware of their and their patients’ cultural backgrounds can better achieve mutual understanding within the patient encounter and focus on culturally appropriate healthcare interventions.
4

Three
Initiatives
PAGE 5

The three initiatives to meet the objective of addressing cultural competence in the hospital are:
1. Creating a cultural competency training program for healthcare staff
2. Developing a policy and procedure for addressing patient cultural diversity
3. Establishing a diversity and inclusion committee

Creating a cultural competency training program for healthcare staff is essential in ensuring that all hospital staff members understand and respect the cultural background of their patients (“Cultural competence training for healthcare professionals, “n.d.). This program should provide staff with the necessary knowledge and skills to effectively interact and communicate with patients from various cultural backgrounds. Developing a policy and procedure for addressing patient cultural diversity is another crucial step in achieving cultural competence in the hospital. This policy should include guidelines and protocols for handling cultural and linguistic differences between patients and staff and methods to ensure that medical decisions are made with patients’ best interests in mind (Why a DEI committee is essential for your nonprofit, 2023). Finally, establishing a diversity and inclusion committee promotes cultural competency in the hospital. This committee should identify and address cultural and linguistic differences within the hospital and monitor the effectiveness of existing cultural competency initiatives.

Creating a cultural competency training program in the next 30 days
PAGE 6

Creating a cultural competency training program for healthcare staff is crucial because it focuses on skills and knowledge that value diversity, understand and respond to cultural differences, and increase awareness of providers’ and care organizations’ cultural norms (“Cultural competence training for healthcare professions,” n.d.). This program will provide healthcare staff with the skills and knowledge to effectively interact with patients from different cultural backgrounds. In the next 30 days this training will focus on understanding the need for diversity and inclusion in the healthcare system, evaluating the value of cultural competence to quality improvement, and examining the relationship between patient satisfaction and employee satisfaction related to diversity and inclusion (“Cultural competence training for healthcare professions,” n.d.). The program will include a training activity related to cultural competence and quality improvement. This training will teach healthcare staff the necessary skills to provide quality care for diverse patient populations.
6

Background to Training
Analysis of the need for diversity & inclusion awareness

PAGE 7

The need for diversity and inclusion awareness is growing in healthcare organizations. Diversity and inclusion in healthcare organizations are essential for providing quality care and promoting patient satisfaction. Research has shown that when healthcare staff is aware of diversity and inclusion, they are better able to work with a diverse patient population (“Diversity and inclusion best practices in Healthcare,”n.d.). Diversity and inclusion initiatives in healthcare organizations should include training and education on cultural competency and awareness, which provides an understanding of how culture and identity impact healthcare decisions and outcomes. Additionally, initiatives should focus on developing an environment where all patients feel welcome, respected, and valued. Lastly, healthcare organizations should adopt policies and practices that promote diversity and inclusion, such as recruiting and promoting a more diverse workforce (“Diversity and inclusion best practices in Healthcare,”n.d.). By increasing diversity and inclusion awareness, healthcare organizations can create an environment where all patients receive the quality, equitable care they deserve.
7

Background to Training
Value of cultural competence in QI

PAGE 8

Cultural competence is a critical factor for quality improvement in healthcare. It involves the ability of healthcare professionals to effectively interact with patients from different cultural backgrounds, creating an environment of respect, understanding, and acceptance (Cultural competence in health care, 2019). Cultural competence enables healthcare providers to recognize and eliminate potential cultural barriers preventing patients from accessing and receiving quality care. Furthermore, it facilitates communication between patients and healthcare providers, allowing for a better understanding of the patient’s needs and expectations. Cultural competence also enables healthcare providers to recognize their various patient populations’ cultural and social dynamics and develop interventions and strategies tailored to their needs (Cultural competence in healthcare, 2019). By understanding and respecting their patients’ cultural backgrounds, healthcare providers are better able to provide quality care and improve the health outcomes of all patients.
8

Background to Training
Relationship of patient satisfaction & employee satisfaction related to D & I

PAGE 9

Diversity and inclusion in healthcare are essential to providing quality care and creating a positive environment for patients and employees. Healthcare staff knowledgeable about diversity and inclusion can better provide quality care to diverse patient populations. This leads to improved patient satisfaction and improved employee satisfaction. Additionally, healthcare staff knowledgeable about diversity and inclusion can create a safe and welcoming environment for all patients and staff. This creates an atmosphere of openness and respect, leading to improved patient and employee satisfaction. Diversity and inclusion are essential for healthcare organizations to foster trust and build positive patient relationships, leading to better health outcomes and a more positive experience for everyone.
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TRAINING
Course-Activity
Outline
PAGE 10

The training activity related to cultural competence and quality improvement is designed to help healthcare staff gain the knowledge and skills necessary to effectively interact with patients from different cultural backgrounds and provide quality care for diverse patient populations. The training will include an overview of the need for diversity and inclusion awareness, an evaluation of the value of cultural competence in quality improvement, and an examination of the relationship between patient satisfaction and employee satisfaction related to diversity and inclusion.
10

Lesson 1: Overview of the need for diversity and inclusion awareness.

Lesson 2: Evaluation of the value of cultural competence in quality improvement.

Lesson 3: Examination of the relationship between patient satisfaction

Lesson 4: Employee satisfaction related to diversity and inclusion

Lesson 5: Summary

Course
Outline
PAGE 11

(“Washington State University,” n.d.)

Being culturally aware allows us to acknowledge our worldviews and heritage. We better understand the differences in the customs and beliefs of others. Exploring and educating ourselves about different cultures helps us to strengthen ourselves. Organizational culture is all of a company’s beliefs, values, and attitudes and how these influence the behavior of its employees. Culture affects how people experience an organization and what it’s like for a customer to buy from or a supplier to work with it.
11

We will cover these skills

Explore personal and cultural values, biases, prejudices, and views.

Identify similarities and differences among cultures.

Recognize our own culture(s), including organizational culture.

First Skill

Explore personal and cultural values, biases, prejudices, and views.
PAGE 12
First Skill
Second Skill
Third Skill
Conclusion

Cultivating self-awareness to uncover biases about others can promote practices that encourage engaging, interactive, cooperative, culturally responsive environments that focus on a growth mindset for patients and staff capabilities and potential. Learning more about other cultures and being aware of current events is often key in learning about various cultural groups’ points of view (“Cultural Competence: An Important Skill Set for the 21st Century, “n.d.). When working with people from different cultural backgrounds, it can be useful to learn about their culture’s practices, values, and beliefs. For example, learning about the languages spoken in their communities, child-rearing practices, or religious traditions can help us understand and interact with individuals and groups of various backgrounds.
12

Second Skill

First Skill
Second Skill
Third Skill
Conclusion
PAGE 13
Identify similarities and differences among cultures.

Comparing is a way to identify similarities and differences between cultures. Understanding cultures will help us overcome and prevent racial and ethnic divisions. Focusing on cultural differences also helps you learn to correctly interpret and make sense of the behavior of others. Finding similarities between cultures allows us to form a potential connection with our counterparts who may feel like they are just a cultural stereotype if we avoid building that cultural bridge.
13

Third Skill
Recognize our own culture(s), including organizational culture..

First Skill
Second Skill
Third Skill
Conclusion
PAGE 14

Being culturally aware allows us to acknowledge our worldviews and heritage (“Importance of cultural awareness,” n.d.). We better understand the differences in the customs and beliefs of others. Exploring and educating ourselves about different cultures helps us to strengthen ourselves. Organizational culture is all of a company’s beliefs, values, and attitudes and how these influence the behavior of its employees (“What is organizational culture,” n.d.). Culture affects how people experience an organization and what it’s like for a customer to buy from or a supplier to work with it.

First Lesson Summary
Here is what we learned

How to explore personal and cultural values, biases, prejudices, and views.

Ways to identify similarities and differences among cultures.

Recognize our own culture(s), including organizational culture

PAGE 15
First Skill
Second Skill
Third Skill
Conclusion

The staff has learned the importance of diversity and inclusion awareness for effective patient care. They understand the value of cultural competence in quality improvement, as it allows for better patient outcomes and greater patient satisfaction. They have also explored the relationship between patient and employee satisfaction regarding diversity and inclusion. The staff has learned that when healthcare systems try to be more inclusive, it can increase employee job satisfaction and improve patient care. For healthcare organizations to provide the best possible care, it is important for staff to be aware of different cultural backgrounds, values, and beliefs and ensure that all patients are treated with respect and care. Diversity and inclusion are essential to providing quality care.
15

Culture Competency Training Activity
PAGE 16

The game of “Two Truths and A Lie” is an excellent culture-building activity and conversation starter for diverse groups. The more complex the lie, the more your colleague will have to use their critical thinking skills to poke holes in your tale, like figuring out whether the timeframe makes sense or the facts are accurate.For this activity, have everyone thinks of three things to say about themselves, of which two should be accurate and one should be a lie. The participants take turns telling the group the truth and the falsehood. The remainder of the team then debates and ultimately votes on which was the lie. The game is fun for team members to learn more about one another.
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References

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References
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References
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References
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Running head: EXECUTIVE SUMMARY 1

Deliverable Six: Executive Summary

LaToya T. Benson

Rasmussen University Online

Healthcare Quality Management

February 28, 2023

Dr. Dawn Ide

Purpose

Evidence-based medicine and

quality improvement

are the most used and essential terms in the healthcare system. Evidence-based practice refers to the care for specific patients by addressing questions relevant to systematic and operational performances to improve safety (Engle et al.,2021). In contrast, quality improvement refers to revising or building a new process using collected data from the target site to enhance the quality of healthcare outcomes. See the figure below:

Evidence-based practice is about translating existing evidence and applying it to clinical decision-making (Ginex,2023). The purpose of evidence-based practice is to utilize the best evidence available to make effective and realistically applicable decisions. The most effective and productive evidence for decision-making stems from research and literature. In clinical settings, clinicians and primary healthcare providers utilize opinions and study proposed by leaders and field experts to guide their practice.

Quality improvement initiatives are essential to patient care, including reducing medical errors, improving access to care, improving patient safety, and improving care coordination. These quality initiatives are essential to ensure that healthcare is being delivered to patients in an accurate and expected manner. Integrating quality improvement (QI) and evidence-based practice (EBP) into the healthcare setting can improve patient outcomes, increase quality, and reduce the cost of care. In a broader context, these can also apply to the practice’s operational and logistical aspects (Grys,2022). As healthcare institutions become ever more complex and our focus on patient experience expands, nurses are leading and participating in

research studies

, evidence-based practice (EBP) projects, and
quality improvement (QI) initiatives to improve patient outcomes (Ginex,2023).

EBP and QI have

subtle differences and frequent overlaps

, making it challenging for nurses to identify the best option to investigate a clinical problem (Ginex,2023). For example, EBP is used to care for individual patients, address operational and systemic questions, or improve safety or quality outcomes. QI projects are used to fix or build a new process specific to the local practice and informed by local data and evidence from the literature. The purpose of QI projects is to

correct workflow processes, improve efficiencies, reduce variations in care, and address clinical administrative or educational problems

(Ginex,2023). An example of a QI project is assessing and implementing urinary catheter removal policies to remove catheters within a defined timeframe. This report aims to compare EBP and QI processes and make recommendations to integrate the EBP into the QI initiatives.

Threats and Prevention

There are many barriers to implementing quality initiatives. These barriers include lack of funding, lack of staff training and resources, lack of support from management, lack of buy-in from clinicians, lack of leadership, poor communication, resistance to change and lack of data systems and analytics infrastructure (Barriers to quality improvement in healthcare, 2022). There are also many barriers to implementing patient quality initiatives. These barriers are lack of awareness, legal issues, demographics, and severity of illness (Importance of patient safety, 2020). Quality improvement is the framework used to systematically improve care. Quality improvement seeks to standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients, healthcare systems, and organizations.

Quality improvement processes can prevent these threats by using quality improvement methodologies such as the Lean Six Sigma (Advance in healthcare with Lean Six Sigma, 2021).
The Lean Six Sigma is defined as a fact-based, data-driven philosophy of improvement that values defect prevention over defect detection. Lean Six Sigma methodologies are critically important in healthcare because they can reduce defects that can result in medical errors (Advance in healthcare with Lean Six Sigma, 2021). See the figure below:

When applied correctly, this methodology can lead to happier customers and increased revenue. In the healthcare industry, defects can affect revenue and customer satisfaction, which can also mean the difference between life and death. Using Six Sigma to improve healthcare quality can:

· Shorten wait times in hospitals and private practices-

· Prevent falls and injuries in hospitals and nursing homes.

· Reduce medication errors when prescribing and administering drugs or filling prescriptions.

· Increase turnaround time for lab results.

For example, to improve and shorten emergency room wait times, the organization must first define the problem(s). Second, measure the current check-in process and gather data for each step. Third, analyze the data collected from each stage, looking for elements and identifying the root cause. Fourth, develop and test solutions to improve check-ins. Fifth, Ensure the new check-in procedure stays on course by frequently monitoring and documenting.

Recommendations

Integrating evidence-based practice into quality improvement initiatives would help make literature-informed decisions and integrate effective strategies. The evidence-based practice incorporates the latest and best available literature evidence to address a patient’s unique values and preferences EBP (Assmairan et al., 2021). Integrating EBP into quality improvement initiatives is crucial because of innumerable benefits. It will enable healthcare organizations to build a vital infrastructure by standardizing nursing practices and improving clinical patient care outcomes EBP (Assmairan et al., 2021). Also, address patient safety concerns by managing all the possible threats. Therefore, it is recommended that for the successful integration of EBP in clinical settings into quality improvement initiatives, it should be part of nurse education and training from the start EBP (Assmairan et al., 2021). It is also implemented in healthcare organizations to achieve tangible positive outcomes.

Strategic Plan

This plan will provide strategic direction for all stakeholders in improving patient safety in their practice domain through policy actions and implementing recommendations at the point of care. Patients are drivers of healthcare organizations. Therefore, the organization should prioritize its preferences. The selected quality improvement model is Lean Six Sigma. The Lean Six Sigma model identifies and prioritizes problems based on customer needs. This model aims to control and understand variations in an organization’s processes. Healthcare organizations can use this model to prioritize required problems and the effectiveness of proposed initiatives to address those problems. Patient safety issues are the priority of this strategic plan. To enforce the Lean Six Sigma Model, a group of trained healthcare professionals must identify issues and propose practical solutions. The Lean Six Sigma approach is intensive because it requires time and effort.

Mission

The mission of this quality improvement model is to improve patient safety by eliminating barriers and threats existing in healthcare organizations.

Vision

The vision of this quality improvement model is to maintain a patient-centered culture within the organization to enhance patient satisfaction and improve patient care outcomes.

Goals/Objectives

The organization aims to maintain a positive healthcare culture in which nurses and healthcare practitioners are knowledgeable and aware of individual patient needs to enhance their satisfaction. By implementing this model healthcare preferences of patients would be met.

SWOT Analysis

Strengths

· Has A Proactive Approach

· Customer Driven

· Improves customer satisfaction.

· Helps in avoiding waste

· Offers Quality Certification

(Cernjava,.n.d.)

Weaknesses

· Extremely costly.

· Requires huge amounts of statistical data.

· Difficult implementation

· Total participation is required.

(Cernjava,.n.d.)

Opportunities

· Reduce the likelihood of errors.

· Increase Effectiveness

· To determine the outputs or features that must be correct to satisfy the customer.

(Cernjava,.n.d.)

Threats

· Lack of consistent training

· Lack of Organization

· Loss of Transparency

· there is a gap between the relity of a situation

(Cernjava,.n.d.)

References

Assmairan, K., Obeidat, R., & AbuAlrub, S. (2021). Evidence-based practice beliefs and implementations: a cross-sectional study among undergraduate nursing students.
BMC Nursing,
20(2). https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-020-00522-x

Černjava, I. (n.d.).
Advantages & disadvantages of Six sigma methodology. LinkedIn. Retrieved March 2, 2023, from https://www.linkedin.com/pulse/advantages-disadvantages-six-sigma-methodology-igor-cernjava#:~:text=The%20main%20advantage%20of%20Six,customer%20is%20considered%20a%20defect.

Engle, R. L., Mohr, D. C., Holmes, S. K., Seibert, M. N., Afable, M., Leyson, J., & Meterko, M. (2021). Evidence-based practice and patient-centered care: Doing both well. Health care management review, 46(3), 174–184. https://doi.org/10.1097/HMR.0000000000000254

Ginex, P. K. (2023, January 13).
The difference between quality improvement, evidence-based practice, and research. ONS Voice. Retrieved February 27, 2023, from

https://voice.ons.org/news-and-views/oncology-research-quality-improvement-evidence-based-practice

Importance of patient safety. Maryville Online. (2020, November 6). Retrieved March 1, 2023, from https://online.maryville.edu/blog/importance-of-patient-safety/.

Grys, Crystal A. MSN, RN. Evidence-based practice, quality improvement, and research: A visual model. Nursing 52(11):p 47-49, November 2022. | DOI: 10.1097/01.NURSE.0000889812.89287.45

Purdue University. (2021, November 3).
Advance in healthcare with Lean Six Sigma – LSS Online – Purdue. Lean Six Sigma Online Certification & Training at Purdue University. Retrieved March 1, 2023, from https://www.purdue.edu/leansixsigmaonline/blog/healthcare-advancement-with-lean-six-sigma/.

Quality Gurus. (2022, July 30).
Barriers to quality improvement in healthcare. Quality Gurus. Retrieved March 1, 2023, from https://www.qualitygurus.com/barriers-to-quality-improvement-in-healthcare/#:~:text=These%20include%20lack%20of%20funding,data%20systems%20and%20analytics%20infrastructure.

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