Service Learning - Sarah Rousseau, BSN, RN Portfolio · Web viewA general plan for change will be introduced as well as the ethical implications for change. Quality Improvement in

Running Head: QUALITY IMPROVEMENT 1

Quality Improvement in Skilled Nursing Facilities

Sarah Rousseau

Ferris State University

QUALITY IMPROVEMENT 2

Abstract

The following will identify an area in need of quality improvement. It will discuss high

reliability standards, just culture and quality improvement models in relation to the identified

quality improvement need. A general plan for change will be introduced as well as the ethical

implications for change.


Quality Improvement in Skilled Nursing Facilities

The healthcare industry has undergone many changes since its inception. Much of what

we do today as nurses has evolved because of quality and safety improvements. These are a

continuous part of the healthcare industry. We are always looking for ways to change and

improve the way in which we provide care for our patients. Patient safety is at the forefront of

everything that we do. As nurse leaders it is our job to assess areas of concern related to patient

care and help to implement change in identified problem areas (Sherwood and Barnsteiner,

2012). When looking at areas of concern in skilled nursing facilities, patient falls is one area that

must be addressed. The following will look at the issue of patient falls; describe a plan to

address this issue, and how a quality and safety improvement plan could potentially reduce the

number of patient falls in a skilled nursing facility.

Needs Assessment

Patient falls and injury related to those falls is an issue that we all deal with no matter

what type of healthcare environment we work in. In the skilled nursing facilities patient falls not

only contribute to pain and injury but also lead to an average of 1,800 deaths each year (U.S.

Department of Health and Human Services, 2012). Patients that fall do not typically fall one

time, according to Rubenstein, Robbins, Josephson, Schulman and Osterweil the average is 2.6

falls per year (1990).

The number of falls on unit A has risen over the last year. Different variables can be

attributed to the increasing number. Variables include: higher acuity residents, floating direct

care staff, and changing residents to name a few. March 2013 unit A had 12 falls compared to

March 2014 the number of falls nearly doubled to 23. Injuries related to falls varied from no

injury, minor injury, and major injury. Falls with minor injury include: cuts, abrasions, skin


tears, and bruising. Falls with major injury include: head injury, fracture and death. In March

2014 falls with no injury numbered 12, minor injury numbered 7, and major injury 6. The care

that we provide our patients must include safety and reducing the chance of falls and falls with

injury to our patients.

Nursing interventions to prevent further falls for patients include such things as patient

safety alarms, wheelchair modifications, toileting schedules, physical restraints, restorative

nursing care programs when appropriate, as well as changes in transfer and ambulation status.

None of the current interventions being used on the unit have been widely successful in

decreasing the number of falls on the unit. It is understood by the facility that falls will occur,

but if we can implement a successful fall reduction program then we will have successfully

improved the quality and safety of the care provided to our patients. We must develop a plan for

improvement incorporating high reliability standards, just culture principles and quality

improvement models.

High Reliability

High reliability means that a healthcare facility has a relatively failure free operation

overall. The attributes of a high reliability organization (HRO) according to Weick, Sutcliffe,

and Obstfeld include a fixation on failure, hesitation to simplify, operational understanding,

commitment to success, and deferring to the experts whenever needed (1999).

Fixation on failure.

The attributes that Weick, Sutcliffe and Obstfeld have set forth need to be acquired by the

organization so that we can be successful when implementing a fall reduction plan. HROs are

consistently being proactive and looking for ways that any given issue can fail, rather than being

reactive once the failure occurs (The Lewin Group, 2008). Fixating on failure also means that no


matter the size of the failure, the same approach is taken to look at the cause of the failure and

make appropriate adjustments. With a lack of failures an organization can become content with

the process; an HRO on the other hand never becomes content. They are always looking for

ways to adapt and improve.

Hesitation to simplify.

Hesitation to simplify means just that. HROs look at the process in place and resist

simplification if it is working. They understand the problems are multifactorial and do not look

for the simple solution when facing these problems. When a process is adjusted and simplified it

can become too simplified and thus changes the process from being effective to ineffective.

HROs assure that all members of the staff are aware that there are a number of things that could

go wrong, and if things do go wrong it is a multifactorial cause (The Lewin Group, 2008).

Operational understanding.

HROs are constantly looking for flaws in the operation. Understanding the operation is a

large part in being able to identify those flaws. Everyone involved in patient care must be aware

of the system as a whole and what issues can have a direct effect on patient care. According to

the Lewin Group (2008) “it includes awareness by staff, supervisors, and management of broader

issues that can affect patient care, ranging from how long a person has been on duty, to the

availability of needed supplies, to potential distractions”. The Lewin Group (2008) also said that

an understanding of operations “will both reduce the number of errors and allow errors to be

quickly identified and fixed before their consequences become larger”.

Commitment to Success.

An attribute that is paramount to an effective HRO is their commitment to success. This

is achieved by their ability to pay attention to every situation. The HRO will always practice


under the assumption that no matter what safeguards are in place, the system may fail in ways

that are unexpected (The Lewin Group, 2008). These potential failures are anticipated and

prepared for through proper training of staff to work as a team, perform a quick assessment of

the situation, and practice in responding to potential system failures (The Lewin Group, 2008).

Their commitment to success is noted in all aspects of the organization.

Deferring to the experts.

There are experts in every field of study in every profession in the world. These experts

help to guide and shape the environments that we practice in. It is not always the one with the

most experience that has the most knowledge on the subject. An HRO promotes an environment

where staff work together and look to the expert for guidance. The Lewin Group (2008) says “a

high reliability culture requires staff at every level to be comfortable sharing information and

concerns with others – and to be commended when they do so”. There must more of a focus on

teams and less on the hierarchy (The Lewin Group, 2008).

When it comes to the issue of patient falls we need to look to those that have set the bar

high to reduce patient falls and achieved their goals time after time. The organization needs to

become an HRO. We must become a team and foster that teamwork environment. This team

must then assume the attributes of a high reliability organization. We must never be satisfied

with our results and be consistently working on change. Quality Assurance and Performance

Improvement (QAPI) are a new standard set forth by the Centers for Medicare & Medicaid

Services (CMS). A QAPI committee should be formed to review our current falls prevention

program and look at ways to improve for a positive impact. The QAPI should be looking for the

root causes of those falls. This is not time for trial and error in our organization; we need to look


at those who have achieved the goal we are trying to reach. HROs are regularly setting new

goals and achieving them.

Just Culture

Patient falls are an issue that is facing skilled nursing facilities across the country. It is a

problem that will plague us for the unforeseeable future. The cause of the problem is not always

one individual’s fault, it can be a myriad of factors working together to create the problem.

Preventing the problem before it occurs takes an in depth look at the issue. A just culture looks

at not punishing those who make the error or highlight the problem, but look at the issue and

identify what in the system could have led that person to make the error. Don Norman while a

fellow at Apple Computers said:

People make errors, which lead to accidents. Accidents lead to deaths. The standard

solution is to blame the people involved. If we find out who made the errors and punish

them, we solve the problem, right? Wrong. The problem is seldom the fault of an

individual; it is the fault of the system. Change the people without changing the system

and the problems will continue (Marx, 2007).

A just culture means to create an open environment to work in that is fair and also just. It should

incorporate proactive learning as an important piece of that culture. Proactive learning involves

not looking at problems as problems, but seeing them as opportunities for improvement and

understanding.

In this organization we need to adapt to the idea of a just culture. Currently when a

problem arises we do not automatically punish those involved, but we are not looking at the

problem as an opportunity. We can foster a just culture by creating an environment that is less


focused on being punitive, but taking the opportunity to examine each problem and gain a better

understanding of the events that led to the problem itself.

Quality Improvement Models

There are a number of quality improvement models that we can look at for guidance to

change the way we handle each situation. The U.S. Department of Health and Human Services

says that “quality improvement (QI) is not simply an end goal. QI is a continuous process that

employs rapid cycles of improvement” (2014). CMS uses a series of quality measures to rate

patient care in nursing homes across the country. These are used to measure the process, patient

perceptions, and systems currently in place that increase quality patient care (Centers for

Medicare & Medicaid, 2013). CMS has also set quality goals which include: patient-centered,

timely, successful, safe and time sensitive care (CMS, 2013). Quality measures are not just

assessed through observation. The measures come from different aspects such as annual nursing

home surveys, patient health records, reports, and instruments used for assessments (CMS,

2013).

This organization currently looks to those quality measures to help us focus on the care

areas that need attention. We take the information that CMS provides and develop reactive QI

projects to address our deficiencies. A simple thing that can be done is to look at the quality

measures of the other nursing homes in the area. We can be proactive and address those

deficiencies that others have. By doing so, we may prevent problems from arising before they

become a problem for us as well. If areas are identified we can implement the current process

and create a proactive QI project, instead of a reactive one.

Quality Improvement Plan


Addressing the issue of falls on unit A is going to be a process that involves many steps.

I believe we should create a falls reduction committee or a QAPI for falls specifically. Prior to

implementing any new plan we must first look at fall reduction programs that have documented

success. This committee can review fall reduction programs around the country to help guide the

development of a new system (MacCulloch, Gardner, and Bonner, 2007). They can then develop

a new fall reduction program that encompasses successes from those that have tried and

succeeded. Though this cannot be all taken from what others have done. The committee must

remember that we are a system unto ourselves and what has worked for others may not be

feasible or effective in our environment.

The first thing must involve the committee reviewing the causes of previous falls.

Taylor, Parmelee, Brown, and Ousland (2005) say there is not usually one reason that a fall

occurs but a combination of extrinsic and intrinsic factors. It is important that we are aware of

this and that when we review a fall we do not only look for the quick and simple answer, but that

we look deep into the incident and look at all possible causes. The cause of falls can involve

such things as; toileting needs, hunger, thirst, confusion, infection, sleep disturbance and so

many more. A root cause analysis should be performed by the committee for all falls to assist in

identifying areas of concern. Causes that are anticipated can help us in preventing further

incidents.

The current system requires a fall risk assessment upon admission. The committee

should review this assessment and see if each of the identified questions is still appropriate and

revise if necessary. The assessment also should be reviewed for additional completion times,

such as with a change of condition. Should the admission fall risk assessment be used or should

a supplemental assessment be developed are questions the committee should address.


The committee should develop a best practice system to be put into place to address

identifiable causes in relation to fall occurrences. Traci Treasure (2014) developed a best

practices tip sheet for the Medicare Quality Improvement Organization for Idaho and

Washington. The tip sheet included: addressing noise reduction, checking patients hourly,

reducing sleep disturbances, reducing physical restraints, reducing patient safety alarms,

individualized fall prevention care plans, reviewing falls, involving family and residents with

the interdisciplinary team when investigating falls, and increasing strength and balance whenever

possible (Treasure, 2014). The committee at first should focus on only a few new best practice

strategies, if the committee takes on too many it will be difficult to tell which have a positive

effect on a standalone basis.

In a quick review of the falls from March 2014 on unit A there a few areas of concern

that can be quickly identified. Currently the average resident on unit A has 1.2 alarms. The

alarms that are in place do not appear to be reducing falls, but simply alerting staff that there has

been a fall which is not the intention of the alarm system. This is just one possible cause of falls,

it is imperative that we address this issue to help prevent further incident. Willy, and Osterberg

(2014) found that with any fall reduction program, a well-organized and uniform approach help

to achieve change and positive outcomes.

Ethical Implications

Nurses have an ethical responsibility to our patients to provide them with the best quality

care. That quality of care involves a focus on patient safety and what we can do to prevent

incident and improve safety. Quality of care for our patients requires respecting the patient as an

individual and not an illness (Hughes, 2008). Nurses must be honest with patients to help foster

open lines of communication. We must work together to provide the best quality of care. The


development of a fall reduction committee or QAPI will help to facilitate improved quality of

care.

Implementing change in regards to falls can have a lasting impact on the healthcare

community and nursing as a whole. If we can reduce the number of falls and injury related to

falls in our patients, then we have succeeded. The less falls there are the less medical care may

be necessary, thus allowing patients to have more freedoms in their daily lives. A successful

falls reduction program can and should be shared with other skilled nursing facilities so that they

may begin to initiate change in their current practice. As nurses we are constantly evolving and

changing and it is our responsibility to help foster that change in others through both our

successes and failures.

Summary

Quality improvement is a major focus in healthcare today, and we must get on board.

Identifying areas of concern is a step toward quality improvement. There is a great need on unit

A for a reduction in falls. We as nurses have the ability to implement a change that can have

lasting effects, and if successful can be implemented throughout the facility. To improve our

quality of care we must fully understand high reliability standards and what they mean for us. If

we adapt to the concept of never being satisfied and always looking for ways to improve we are

much more likely to identify problem areas before they can have a negative impact. We must

also implement a just culture, and focus less on punishment for the problem and more on how to

fix the problem at hand, as well as fostering education and open communication. Also, utilizing

the quality measures as a model for change will not only allow us to look at the problems that we

have but the problems of other facilities so that we can address them as well if need be.


The development of a successful fall reduction program begins today. A committee of

those with like-minded goals must be formed to focus on the need at hand. The committee will

begin by addressing the increasing number of falls on unit A. Anderson, Campos, Earley,

Johantges, Johnson and O’Connor (2009) said “the most well-designed interventions for fall

prevention are ineffective if they are not selected and implement appropriately” (p. 159). This

will be a process that may take a while, but if it implemented appropriately, constantly evaluated

and adjusted we may be able to have a significant impact on the quality of care our patients

receive.


References

Anderson, G., Campos, T., Earley, V., Johantges, D., Johnson, C. L., & O'Connor, E. (2009).

Achieving sustained reduction in patient falls. In N. Dunton & I. Montalvo (Eds.),

Sustained improvement in nursing quality: Hospital performance on NDNQI

indicators, 2007-2008 (pp.155-160). American Nurses.

Falls in nursing homes. (2012, February 29). Retrieved April 21, 2014, from

http://www.cdc.gov/homeandrecreationalsafety/falls/nursing.html

Hughes, R. G. (2008). Nurses at the "sharp end" of patient care. In R. G. Hughes (Ed.), Patient

safety and quality: An evidence-based handbook for nurses (pp. 1-7-1-36). Agency for

healthcare Research and Quality.

MacCulloch, P. A., Gardner, T., & Bonner, A. (2007). Comprehensive fall prevention programs

across settings: A review of the literature. Geriatric Nursing, 28(5), 306-311.

Marx, D. (n.d.). Patient safety and the "just culture" [ppt]. Retrieved April 26, 2014, from New

York Department of Health website: http://www.health.ny.gov/professionals/patients/

patient_safety/conference/2007/docs/patient_safety_and_the_just_culture.pdf

Quality measures. (2013, April 9). Retrieved April 24, 2014, from

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/QualityMeasures/index.html

Rubenstein, L. Z., Robbins, A. S., Josephson, K. R., Schulman, B. L., & Osterweil, D. (1990).

The value of assessing falls in an elderly population: A randomized clinical trial. Annals

of Internal Medicine, 113(4), 308-316.

Sherwood, G., & Barnsteiner, J. (2012). Quality and safety in nursing: A competency approach

to improving outcomes. Hoboken, NJ: Wiley-Blackwell


Taylor, J. A., Parmelee, P., Brown, H., & Ouslander, J. (2005, October). The falls management

program: A quality improvement initiative for nursing facilities. Atlanta, GA: Center

for health in Aging.

The Lewin Group. (2008, April). Becoming a high reliability organization: Operational advice

for hospital leaders. Falls Church, VA: The Lewin Group.

Treasure, T. (n.d.). Nursing home quality care collaborative [Pamphlet]. Qualis Health.

U.S. Department of Health and Human Services. (2014). What is quality improvement?

Retrieved April 18, 2014, from

http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/QualityImprovement/

whatisqi.html

Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability: Processes of collective

mindfulness. Research in Organizational Behavior. 1999; 21:81-123.

Willy, B., & Osterberg, C. (2014). Strategies for reducing falls in long-term care. Annals of

Long-Term Care, 22(1), 23-32.

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Service Learning - Sarah Rousseau, BSN, RN Portfolio · Web viewA general plan for change will be introduced as well as the ethical implications for change. Quality Improvement in